CalgaryBlackBook 2013

The Calgary Black Book:
Approaches to Medical
Presentations
2010/2011 Edition
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Thls materlal ls for educatlonal purposes only. |t ls not to be used to
make medlcal declslons. Medlcal declslons should be made only wlth
the guldance of a llcensed medlcal professlonal.
whlle enorts have been made to ensure accuracy of the content wlthln,
the accuracy ls not guaranteed.
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Lucas Gurskv
Ting Li
Ionathan Dvkeman
Kathv Truong

Svlvain Coderre Henrv Mandin
Kevin McLaughlin Brett Poulin Bruce Wright

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Third Edition (2010)
M. Mustafa Hirji
Linnea Duke
LY Y
5IF$BMHBSZ#MBDL#PPL"QQSPBDIFTUP.FEJDBM1SFTFOUBUJPOT
Thlrd Ldltlon (20l0). Plrst Prlntlng.
Copyrlght 2007-20l0. Paculty of Medlclne, Unlverslty of Calgary. All Plghts Peserved.
Plrst Ldltlon 2007 (Peprlnt 2008)
Second Ldltlon 2009 (Peprlnts 2009, 20l0)
|S8N: Pendlng Asslgnment
No part of thls publlcatlon may be reproduced or transmltted ln any form or by any means, electronlc or
mechanlcal, lncludlng photocopylng, recordlng, or any lnformatlon storage and retrleval system, wlthout
permlsslon ln wrltlng.
Thls materlal ls for educatlonal purposes only. |t ls not to be used to make medlcal declslons. Medlcal
declslons should be made only wlth the guldance of a llcensed medlcal professlonal.whlle efforts have been
made to ensure accuracy of the content wlthln, the accuracy ls not guaranteed.
The 8lack 8ook Proect may be contacted at:
Undergraduate Medlcal Lducatlon
Paculty of Medlclne
Unlverslty of Calgary
Health Sclences Centre
3330 Hospltal Drlve N.w.
Calgary, Alberta, Canada T2N 4Hl
blackbkucalgary.ca
Medlcal presentatlon schemes concelved by Henry Mandln.
The Calgary 8lack 8ook Proect founded by 8rett Poulln.
Prlnted ln Calgary, Alberta, Canada.
Thlrd Ldltlon 20l0
v
Table of Contents
Message from the Editors xiv
Introduction to Schemes xv
Cardiovascular Presentations 1
Chest Discomfort: Cardiovascular 2
Chest Discomfort:
Pulmonary/Mediastinal 3
Chest Discomfort: Other 4
Hypertension 5
Hypertension in Childhood 6
Hypertension in Pregnancy 7
Shock 8
Syncope 9
Palpitations 10
Pulse Abnormalities 11
Left-Sided Heart Failure 12
Right-Sided Heart Failure 13
Systolic Murmur: Benign & Stenotic 14
Systolic Murmur: Valvular & Other 15
Diastolic Murmur 16
Respiratory Presentations 17
Chest Trauma 18
Cough, Dyspnea, & Fever 19
Chronic Cough 20
Chest Discomfort: Cardiac 21
Chest Discomfort: Pulmonary 22
Dyspnea: Cardiac 24
Dyspnea: Other 25
Acute Dyspnea 26
Excessive Daytime Sleepiness 27
Hemoptysis 28
Hypoxemia 29
Mediastinal Mass 30
vi
Lung Nodule 31
Pleural Effusion 32
Pneumonia Treatment Failure 33
Pulmonary Hypertension 34
Suspected Acid-Base Disorder 35
Hematologic Presentations 37
Approach to Bleeding/Bruising:
Platelets & Vascular System 38
Coagulation Proteins 39
Prolonged PTT, Normal PT (INR):
Bleeding Tendency 40
No Bleeding Tendency 41
Prolonged PT (INR), Normal PTT 42
Approach to
Prolonged PT (INR), Prolonged PTT 43
Suspected Deep Vein Thrombosis 44
Suspected Pulmonary Embolus 45
Overall Approach to Anemia 46
Approach to Anemia:
Mean Corpuscular Volume 47
Anemia with Low MCV 48
Anemia with Normal MCV 49
Anemia with Elevated MCV 50
Thrombocytopenia 51
Neutropenia:
Decreased Neutrophils Only 52
Neutropenia: Sequestration
& Decreased Production 53
Neutrophilia 54
Polycythemia 55
Lymphadenopathy: Localized 56
Lymphadenopathy: Diffuse 57
Approach to Splenomegaly 58
Fever in the Immunocompromised Host 59
Gastrointestinal Presentations 61
Abdominal Distention: Ascites 63
Abdominal Distention: Bowel Dilatation 64
Abdominal Distention: Other Causes 65
vii
Abdominal Pain (Adult):
Acute - Diffuse 66
Acute - Localized 67
Chronic - Constant 68
Chronic - Crampy/Fleeting 69
Chronic - Post-Prandial 70
Anorectal Pain 71
Acute Diarrhea 72
Stool Incontinence 73
Chronic Diarrhea:
Steatorrhea & Large Bowel 74
Chronic Diarrhea: Small Bowel 75
Constipation (Adult): Altered Bowel
Function & Idiopathic 76
Constipation (Adult): Secondary Causes 77
Constipation (Pediatric) 78
Dysphagia 79
Mouth Disorders: Adult & Elderly 80
Mouth Disorders: Pediatric 81
Nausea & Vomiting:
Gastrointestinal Disease 82
Nausea & Vomiting:
Other Systemic Disease 83
Nausea & Vomiting
with Associated Symptoms 84
Upper Gastrointestinal Bleed
(Hematemesis/Melena) 85
Lower Gastrointestinal Bleed 86
Weight Loss 87
Weight Gain 88
Hepatomegaly 89
Jaundice 90
Elevated Liver Enzymes 91
Liver Mass 92
Abdominal Mass 93
Renal Presentations 95
Acute Renal Failure 96
viii
Chronic Renal Failure 97
Generalized Edema 98
Hypertension 99
Hematuria 100
Proteinuria 101
Hyponatremia 102
Hypernatremia 103
Hypokalemia 104
Hyperkalemia: Intracellular Shift 105
Hyperkalemia: Reduced Excretion 106
Metabolic Acidosis: Elevated Anion Gap108
Metabolic Acidosis: Normal Anion Gap 109
Metabolic Alkalosis: Contracted EABV 110
Metabolic Alkalosis: Expanded EABV 111
Increased Urinary Frequency 112
Polyuria 113
Dysuria 114
Nephrolithiasis 115
Urinary Incontinence 116
Urinary Tract Obstruction 117
Renal Mass: Solid 118
Renal Mass: Cystic 119
Scrotal Mass 120
Endocrinologic Presentations 121
Abnormal Serum TSH 123
Hyperthyroidism 124
Hypothyroidism 125
Adrenal Mass: Benign 126
Adrenal Mass: Malignant 127
Amenorrhea 128
Breast Discharge 129
Gynecomastia: Increased Estrogen &
Increased HCG 130
Gynecomastia: Increased LH &
Decreased Testosterone 131
Male Sexual Dysfunction 132
Hirsutism 133
Hirsutism & Virilization:
Androgen Excess 134
Hirsutism & Virilization: Hypertrichosis 135
ix
Sellar/Pituitary Mass: Size 136
Sellar/Pituitary Mass 137
Short Stature 138
Tall Stature 139
Hypocalcemia: Low Phosphate 140
Hypocalcemia: High Phosphate 141
Hypercalcemia: Normal/High PTH 142
Hypercalcemia: Low PTH 143
Hypoglycemia 144
Hyperglycemia 145
Hypophosphatemia 146
Hyperphosphatemia 147
Abnormal Lipid Profile:
Combined & Decreased HDL 148
Abnormal Lipid Profile: Increased LDL &
Increased Triglycerides 149
Weight Gain/Obesity 150
Neurologic Presentations 151
Altered Level of Conciousness:
Approach 153
GCS 7 154
Cognitive Impairment 155
Hemiplegia 156
Gait Disturbance 157
Falls in the Elderly 158
Movement Disorder: Hyperkinetic 159
Movement Disorder: Tremor 160
Movement Disorder: Bradykinetic 161
Vertigo/Dizziness: True Vertigo 162
Vertigo/Dizziness: Dizziness 163
Syncope 164
Spell/Seizure: Epileptic Seizure 165
Spell/Seizure: Secondary Organic 166
Spell/Seizure: Other 167
Mechanisms of Pain 168
Headache: Primary 169
Headache: Secondary,
with Red Flag Symptoms 170
without Red Flag Symptoms 171
x
Back Pain 172
Dysarthria 173
Aphasia: Fluent 174
Aphasia: Non-Fluent 175
Peripheral Weakness 176
Peripheral Weakness:
Sensory Changes 177
Stroke: Intracerebral Hemorrhage 178
Stroke: Subarachnoid Hemorrhage 179
Stroke: Ischemia 180
Unintentional Weight
Loss in the Elderly 181
Obstetrical & Gynecological
Presentations 183
Prenatal Screening Tests 185
Bleeding in Pregnancy: <20 Weeks 186
Bleeding in Pregnancy: 2nd and 3rd
Trimesters 187
Recurrent Pregnancy Loss 188
Growth Discrepancy:
Small for Gestational Age/Intrauterine
Fetal Growth Restriction 189
Growth Discrepancy:
Large for Gestational Age 190
Non-Reassuring Fetal Status
(Fetal Distress) 191
Abnormal Fetal Heart Rate Tracing 192
Postpartum Hemorrhage 193
Abnormal Genital Bleeding 194
Vaginal Discharge 195
Amenorrhea: Primary 196
Amenorrhea: Secondary 197
Acute Pelvic Pain 198
Chronic Pelvic Pain 199
Infertility: Female 200
Infertility: Male 201
Ovarian Mass 202
Pelvic Mass 203
Pelvic Organ Prolapse 204
Breast Disorders 205
xi
Dermatologic Presentations 207
Morphology of Skin Lesions:
Primary Skin Lesions 209
Secondary Skin Lesions 210
Comedone 211
Vascular Lesions 212
Skin Rash: Eczematous 213
Skin Rash: Papulosquamous 214
Skin Rash: Vesiculobullous 215
Skin Rash: Pustular 216
Skin Rash: Reactive 217
Disorders of Pigmentation:
Hypopigmentation 218
Hyperpigmentation 219
Skin Ulcer by Etiology 220
Skin Ulcer by Location: Head/Neck 221
Skin Ulcer by Location: Oral Ulcers 222
Skin Ulcer by Location: Trunk/Sacral
Region 223
Skin Ulcer by Location: Genitals 224
Skin Ulcer by Location:
Lower Legs/Feet 225
Hair Loss (Alopecia): Localized 226
Hair Loss (Alopecia): Diffuse 227
Nail Disorders: Primary Dermatologic
DIsease 228
Nail Disorders: Systemic Disease 229
Nail Disorders: Systemic Disease -
Clubbing 230
Mucous Membrane Disorder
(Oral Cavity) 231
Pruritis: Primary Skin Lesion 232
Pruritis: No Primary Skin Lesion 233
Dermatoses in Pregnancy:
Physiologic Changes 234
Specific Skin Condition 235
Genital Lesion 236
Burns 237
xii
Musculoskeletal Presentations 239
Bone Lesion 240
Deformity/Limp 241
Acute Joint Pain 242
Chronic Joint Pain 243
Infectious Joint Pain 244
Inflammatory Joint Pain 245
Vascular Joint Pain 246
Myotomes: Segmental Innervation of
Muscles 247
Pathologic Fractures 248
Guide to Spinal Cord Injury 249
Psychiatric Presentations 251
Anxiety Disorders:
Associated with Panic 252
Anxiety Disorders:
Secondary to a Specific Stressor 253
Anxiety Disorders:
Recurrent Anxious Thoughts 254
Personality Disorders 255
Mood Disorders:
Past Depressive Episode 256
Mood Disorders:
With Psychotic Symptoms 257
Psychotic Disorders 258
Somatoform Disorders 259
Otolaryngologic Presentations 261
Otalgia 262
Hearing Loss 263
Hoarseness: Etiology 264
Hoarseness: Laryngoscopy 265
Smell Dysfunction 266
Tinnitis: Subjective 267
Tinnitis: Objective 268
Ophthalmologic Presentations 269
Pupillary Abnormalities: Isocoria 270
Pupillary Abnormalities: Anisocoria 271
Red Eye: Traumatic 272
xiii
Red Eye: Atraumatic 273
Amblyopia 274
Strabismus 275
Diplopia 276
Acute Vision Loss: Unilateral 277
Acute Vision Loss: Bilateral 278
Chronic Vision Loss: Anatomic 279
Pediatric Presentations 281
Developmental Delay 283
School Difficulties 284
Small for Gestational Age 285
Congenital Anomalies 287
Acute Abdominal Pain 288
Neonatal Jaundice 289
Pediatric Diarrhea 290
Failure to Thrive:
Adequate Calorie Consumption 291
Failure to Thrive:
Inadequate Calorie Consumption 292
Floppy Newborn 293
Depressed/Lethargic Newborn 294
Cyanosis in the Newborn:
Non-Respiratory 295
Cyanosis in the Newborn: Respiratory 296
Pediatric Dyspnea 297
Sudden Unexpected Death in Infancy 298
Enuresis 299
Acute Life Threatening Event 300
Other Presentations 301
Fever & Chills 302
Sore Throat/Rhinorrhea 303
Hypothermia 304
Fatigue 305
Historical Executive Student Editors 307
List of Authors 308
List of Abbreviations 309
xiv [LY
Message Irom the Editors
Welcome to the third edition oI The Calgary Black Book. This edition is the
culmination oI the hard work oI numerous University oI Calgary medical Iaculty
and students. In this edition. we concentrated on improving the overall
organization and Iormatting oI the schemes presented herein. with the primary
goal oI making schemes easier to navigate and recall. We rearranged all oI the
schemes according to speciIic style and structural guidelines so as to provide
continuity Irom one scheme to the next. Secondarily. we have Iocused on
updating and improving scheme content. We hope you will Iind these changes
beneIicial to your learning.
We would be proud to see the Black Book continue to evolve as a useIul and
ubiquitous tool employed by medical students. residents. physicians. nurses. and
other trainees and students within Allied Health Care. As always. we are open to
suggestions on ways to make the Black Book more useIul to our readers. and
welcome such Ieedback Ior consideration in Iuture editions.
Iucas Gursky and Ting Ii. Executive Editors (2009-2010)
xv
Introduction to Schemes
The material presented in this book is intended to assist learners in organizing
their knowledge into information packets, which are more effective for the
resolution of the patient problems they will encounter. There are three major
factors that influence learning and the retrieval of medical knowledge from
memory: meaning, encoding specificity (the context and sequence for learning)
and practice on the task of remembering. Of the three, the strongest influence is
the degree of meaning that can be imposed on information. To achieve success,
experts organize and chunk information into meaningful configurations,
thereby reducing the memory load.
These meaningful configurations or systematically arranged networks of
connected facts are termed schemata. As new information becomes available, it
is integrated into schemes already in existence, thus permitting learning to take
place. Knowledge organized into schemes (basic science and clinical
information integrated into meaningful networks of concepts and facts) is useful
for both information storage and retrieval. To become excellent in diagnosis, it
is necessary to practice retrieving from memory information necessary for
xvi
problem resolution, thus facilitating an organized approach to problem solving
(scheme-driven problem solving).
The domain of medicine can be broken down to 121 (+/- 5) clinical
presentations, which represent a common or important way in which a patient,
group of patients, community or population presents to a physician, and expects
the physician to recommend a method for managing the situation. For a given
clinical presentation, the number of possible diagnoses may be sufficiently large
that it is not possible to consider them all at once, or even remember all the
possibilities. By classifying diagnoses into schemes, for each clinical
presentation, the myriad of possible diagnoses become more manageable
groups of diagnoses. This thus becomes a very powerful tool for both
organization of knowledge memory (its primary role at the undergraduate
medical education stage), as well as subsequent medical problem solving.
There is no single right way to approach any given clinical presentation. Each of
the schemes provided represents one approach that proved useful and
meaningful to one experienced, expert author. A modified, personalized scheme
may be better than someone elses scheme, and certainly better than having no
scheme at all. It is important to keep in mind, before creating a scheme, the five
xvii
fundamentals of scheme creation that were used in the development of this
book. If a scheme is to be useful, the answers to the next five questions should
be positive:
1. Is it simple and easy to remember? (Does it reduce memory load by
chunking information into categories and subcategories?)
2. Does it provide an organizational structure that is easy to alter?
3. Does the organizing principle of the scheme enhance the meaning of the
information?
4. Does the organizing principle of the scheme mirror encoding specificity
(both context and process specificity)?
5. Does the scheme aid in problem solving? (E.g. does it differentiate between
large categories initially, and subsequently progressively smaller ones until
a single diagnosis is reached?)
xviii
By adhering to these principles, the schemes presented in this book, or any
modifications to them done by the reader, will enhance knowledge storage and
long term retrieval from memory, while making the medical problem-solving
task a more accurate and enjoyable endeavour.
Dr. Henry Mandin
Dr. Sylvain Coderre
xix
1
Cardiovascular Presentations
Chest Discomfort: Cardiovascular 2
Chest Discomfort:
Pulmonary/Mediastinal 3
Hypertension 5
Hypertension in Childhood 6
Hypertension in Pregnancy 7
Shock 8
Syncope 9
Palpitations 10
Pulse Abnormalities 11
Left-Sided Heart Failure 12
Right-Sided Heart Failure 13
Systolic Murmur: Benign & Stenotic 14
Systolic Murmur: Valvular & Other 15
Diastolic Murmur 16
Student Editors
Sarah Surette (Section Editor)
Geoff Lampard
Kathy Truong
Lian Szabo
Marc Chretien
Jeff Shrum
Connal Robertson-More
Faculty Editor
Dr. Sarah Weeks
2
Chest Discomfort
Cardiovascular
CHEST DISCOMFORT: Cardiovascular
Outflow
Obstruction
Non-Ischemic Ischemic
Myocardial
Infarction*
Stable/Unstable
Angina*
Aortic
Dissection*
Dilating
Aneurysm*
Pericarditis*
Myocarditis
Aortic
Stenosis
Other
Pulmonary/
Mediastinal
* Denotes acutely life-threatening causes
3
Chest Discomfort
Pulmonary/Mediastinal
CHEST DISCOMFORT: Pulmonary/Mediastinal
Other Cardiovascular
Chest Wall/Pleural Vascular Parenchymal
Pulmonary Embolism*
Pulmonary Hypertension
Pneumothorax*
Pleural Effusion
Pleuritis
Pneumonia*
Tuberculosis
Neoplasm
Sarcoidosis
4
Chest Discomfort
CHEST DISCOMFORT: Other
Musculoskeletal
Other Pulmonary/Mediastinal Cardiovascular
Gastrointestinal
Gastro-Esophageal Reflux
Disease
Biliary Disease
Peptic Ulcer Disease
Pancreatitis*
Esophageal Spasm
Esophageal Perforation*
Neurologic/Psychiatric
Anxiety/Panic
Herpes Simplex Virus/Post-
Herpetic Neuralgia
Somatoform Disorder
Spinal Radiculopathy
5
HYPERTENSION
Hypertension
Volume Dependent
Other Cause: Polycythemia rubra
vera
Secondary (5%)
Onset age < 20 or > 50 years.
No family history. Hypertensive
urgency, Refractory hypertension.
Systemic Vascular
Resistance
(Vasoconstrictive)
Primary (Essential) (95%)
Onset between age 20 and 50.
Positive family history.
No features of secondary hypertension.
Long-Standing
Uncontrolled
Drug Withdrawal
Mislabelled
Repeatedly normal blood pressure
when taken at home, work
or using an ambulatory monitor.
White Coat Hypertension
Masked Hypertension
Definition of hypertension:
Systolic BP < 140mmHg or Diastolic BP < 90mmHg
solated systolic hypertension in the elderly < 160mmHg
Diabetes mellitus/Chronic kidney disease < 130/80mmHg
Renal Parenchymal
Disease
Elevated serum Cr,
Abnormal urine analysis,
Epigastric systolic-diastolic bruit.
Glomerulonephritis
Acute Kidney Injury
Chronic Kidney Disease
Bilateral Renal Artery
Stenosis
Medications
NSAIDs
Oral
Contraceptive
Pill
Mineralocorticoid
Excess
Hypokalemia,
Metabolic alkalosis,
High TTKG.
Primary
Hyperaldosteronism
Licorice
Liddle's Syndrome
Angiotensin II
Excess
Asymmetric kidney size on
ultrasound +/- epigastric
systolic-diastolic bruit.
Unilateral Renal
Artery Stenosis
Radio-femoral
delay
+/- features
of coarctation
Aortic
Coarctation
Catecholamine
Excess
Episodic headache,
sweating & tachycardia.
Pheochromocytoma
6
Hypertension in Childhood
HYPERTENSION IN CHILDHOOD
Children & Adolescents
(11-18 Years Old)
Renal Disease (Parenchymal/
Vascular)
Primary Hypertension
Children (1-10 Years Old)
Renal Disease (Parenchymal/
Vascular)
Aortic Coarctation
Neonates and Young
Infants
Renal Disease (Ischemic/
Congenital)
Aortic Coarctation
Hypercalcemia
Neurogenic Tumors
Umbilical Vessel
Catheterization
7
HYPERTENSION IN PREGNANCY
Hypertension in Pregnancy
(SBP < 140mm Hg, DBP < 90mm Hg, or both)
Pre-existing Hypertension
Diagnosis of chronic hypertension in a pregnant
woman (presents at < 20 weeks gestational age)
Pregnancy Induced Hypertension
Diagnosis in a previously normotensive woman
(presents at > 20 weeks gestational age)
Pre-Eclampsia on
Chronic Hypertension
Chronic Hypertension
Primary
Secondary
No Proteinuria
Gestational
Hypertension
Pre-Eclampsia +
Seizures/Coma
Eclampsia
Proteinuria
(< 0.3g/24hr urine)
Pre-Eclampsia
8
SHOCK
Shock
Warm Extremities Cool Extremities
High JVP Distributive Shock
Anaphylaxis
Sepsis
Burns
Neurogenic
Hypovolemic or
Decompensated Distributive
Shock
Low JVP
Obstructive Shock
Normal/Decreased Breath
Sounds
Tension Pneumothorax
Pulmonary Embolism
Cardiac Tamponade
Cardiogenic Shock
Lung Crackles
9
Syncope
SYNCOPE
Outflow Obstruction
Aortic Stenosis
Mitral Stenosis
Hypertrophic
Cardiomyopathy
Aortic Dissection
Atrial Myxoma
Bradyarrhythmia
Sinus Node Dysfunction
Atrioventricular node
dysfunction
Tachyarrhythmia
Ventricular
Supraventricular
Underfill
Orthostasis
Neural
Vasovagal
Carotid Sinus
Orthostasis
Hypertrophy
Psychiatric
Panic Attack
Hyperventilation
Hysteria
Cardiovascular
Arrhythmia
10
Palpitations
PALPITATIONS
Non-Cardiac Cardiac
Arrhythmias
Supra-Ventricular
Ventricular
Valve Incompetence
Psychiatric
Panic Attack
Generalized Anxiety
Disorder
Increased Output
Anemia
Fever
Pregnancy
Metabolic
Thyrotoxicosis
Hypoglycemia
Pheochromocytoma
Medications
Alcohol
Caffeine
Sympathomimetics
Vasodilators
Cocaine
Nicotine
Rule in/out cardiac history or symptoms
11
Pulse Abnormalities
PULSE ABNORMALITIES
Other
Unequal
Pulses
Aortic
Disease
Dissection/
Aneurysm
Coarctation
Supravalvular
Aortic
Stenosis
Systemic
Pulses
Alternans
Paradoxus
Bisferiens
Corrigan's
Dicrotic
Pulses in
Aortic
Stenosis
Anacrotic
Tardus/
Parvus
Shudder
Obstructive
Arterial
Disease
Takayasu's
Arteritis
Normal
Variant
Rule out Pulsus Paradoxus
12
Left-Sided Heart Failure
Ventricular Diastolic
Dysfunction
LEFT-SIDED HEART FAILURE
Valvular Disease
Ventricular Systolic
Dysfunction
Mitral Stenosis
Mitral Regurgitation
Aortic Stenosis
Aortic Regurgitation
Impaired Contractility
Mitral Stenosis
Transient Myocardial
Ischemia
Chronic Mitral
Regurgitation
Chronic Aortic
Regurgitation
Dilated Cardiomyopathy
Increased Afterload
Uncontrolled
Hypertension
Aortic Stenosis (Severe)
Impaired Ventricular
Relaxation
Transient Myocardial
Ischemia
Left Ventricular
Hypertrophy
Hypertrophic
Cardiomyopathy
Restrictive
Cardiomyopathy
Pericardial Disease
Pericardial Constriction
Pericardial Tamponade
13
Right-Sided Heart Failure
RIGHT-SIDED HEART FAILURE
Cardiac Disease
Left-Sided Heart Failure
Pulmonic Valve Stenosis
Right Ventricular Infarction
Constrictive Pericarditis
Restrictive CArdiomyopathy
Pulmonary Stenosis (rare)
Pulmonary Parenchymal Disease
Chronic Obstructive Pulmonary Disease
Diffuse Parenchymal Lung Disease
Acute Respiratory Distress Syndrome
Chronic Lung Infection
Bronchiectasis
Pulmonary Vascular Disease
Pulmonary Embolism
Primary Pulmonary Arterial Hypertension
14
Systolic Murmur
SYSTOLIC MURMUR: Benign & Stenotic
Benign/Flow/
Hyperdynamic
Pregnancy
Fever
Anemia
Stenotic Incompetent Valve Other
Subvalvular Valvular
Aortic Stenosis
Uni-/Bicuspid
Tricuspid/Degenerative
Rheumatic Fever
Pulmonary Stenosis
Supravalvular
15
Systolic Murmur
SYSTOLIC MURMUR: Valvular & Other
Leaflet/Annulus
Endocarditis
Rheumatic Fever
Marfan's Disease
Hypertrophic
Cardiomyopathy
Dilated
Cardiomyopathy
Prolapse
(myxomatous valve
disease)
Chordae
Tendinae
Rupture
Endocarditis
Rheumatic Fever
Trauma
Papillary Muscle
Dysfunction
Ischemic
Infarct
Rupture
Leaflet
Rheumatic Fever
Endocarditis
Ebstein's Anomaly
Carcinoid
Prolapse
Dilation of Right
Ventricle/Annulus
Myocardial
Infarction
Pulmonary
Hypertension
Stenotic
Incompetent
Valve
Benign/Flow/
Hyperdynamic
Other
Ventricular Septal
Defect
Mitral
Regurgitation
Tricuspid
Regurgitation
16
Diastolic Murmur
DIASTOLIC MURMUR
Late Diastolic
(Pre-Systolic)
Left to Right Shunt
Complete Heart Block
Mid-Diastolic
Mitral Stenosis
Tricuspid Stenosis
Flow increase across AV
valve
Severe Aortic
Regurgitation (Austin Flint
Murmur)
Atrial Myoxoma Prolapse
Early Diastolic
Aortic Regurgitation
Pulmonary Regurgitation
(Graham Steell Murmur)
If Late Diastolic: In the setting of a left to right
shunt there will always be a systolic murmur
17
Respiratory Presentations
Chest Trauma 18
Cough, Dyspnea, & Fever 19
Chronic Cough 20
Chest Discomfort: Cardiac 21
Chest Discomfort: Pulmonary 22
Dyspnea: Cardiac 24
Dyspnea: Other 25
Acute Dyspnea 26
Excessive Daytime Sleepiness 27
Hemoptysis 28
Hypoxemia 29
Mediastinal Mass 30
Lung Nodule 31
Pleural Effusion 32
Pneumonia Treatment Failure 33
Pulmonary Hypertension 34
Student Editors
Katrina Rodrigues (Section Editor)
Geoff Lampard
Shaina Lee
Eric Sy
Lian Szabo
Marc Chretien
Ying Wang
Vanessa Millar
Faculty Editor
Dr. Naushad Hirani
18
CHEST TRAUMA
Chest Trauma
Cardiac Chest Wall
Rib Fractures
Flail Chest
Diaphragm Injury
Lung
Pulmonary Contusion
Pneumothorax
Hemothorax
Pericardial
Tamponade
Pericarditis
Myocardial
Contusion
Coronary Vessel
Aorta
Aortic Rupture
19
COUGH, DYSPNEA, AND FEVER
Cough, Dyspnea, & Fever
Normal Chest X-Ray Abnormal Chest X-Ray
Acute Bronchitis
Acute Exacerbation of Chronic
Bronchitis
Normal Chest X-Ray
Pulmonary Embolus
Bronchiolitis Obliterans
with Organizing
Pneumonia
Wegener's
Granulomatosis
Pneumonia in the
Immunocompetent
Host
Pneumonia in the
Immunocompromised
Host
Bacterial (often non-
pathogenic with immune
competence)
Fungal (e.g. Pneumocystis
jirovecii)
Viral
New/Changed Murmur
Hospital Acquired
Staphylococcus
aureus
Pseudomonas
aeruginosa
Other
Community
Acquired
Mycoplasma
pneumoniae
Chlamydophila
pneumoniae
Streptococcus
pneumoniae
Haemophilus
influenzae
Other
Tuberculosis
Pulmonary Embolus
Bronchiolitis
Obliterans with
Organizing
Pneumonia
Wegener's
Granulomatosis
Peripheral Stigmata
of Subacute
Endocarditis
Left-sided
Endocarditis
Intravenous Drug
User
Right-sided
Endocarditis with
Septic Emboli
20
CHRONIC COUGH
Chronic Cough
Normal Chest X-Ray Abnormal Chest X-Ray
Chronic Obstructive Pulmonary
Disease
Chronic Infection (e.g. Fungal,
Tuberculosis)
Neoplasm
Congestive Heart Failure
Interstitial Disease
Normal Spirometry
Obstructive Disease
(FEV1/FVC <75%)
Asthma
Chronic Obstructive
Pulmonary Disease
Lower Airway
Asthma
Upper Airway
Post-nasal Drip
Sinusitis
Drugs
Angiotensin
Converting
Enzyme Inhibitors
Smoker's Cough
Gastro-Esophageal
Reflux
21
CHEST DISCOMFORT: Cardiac
Chest Discomfort
* Acutely life-threatening causes of chest discomfort
Pulmonary Cardiac Other (30%)
Pericardial
Pericarditis
Effusion
Constriction
Tamponade*
Myocardial
Systolic Dysfunction
Diastolic Dysfunction
Cardiomyopathies
Myocarditis
Valvular
Regurgitation
Stenosis
Sub-Valvular Disease
Vascular
Stable Angina
Acute Coronary
Syndrome*
Thoracic Aortic Dissection*
22
CHEST DISCOMFORT: Pulmonary
*Acutely life-threatening causes of chest discomfort
Chest Discomfort
Pleura
Pneumothorax
Pleurisy
Tension Pneumothorax*
Parenchyma
Pneumonia
Neoplasm
Vascular
Pulmonary Embolus*
23
CHEST DISCOMFORT: Other
* Acutely life-threatening causes of chest discomfort
Chest Discomfort
Neurologic/
Psychogenic
Anxiety/Panic
HZV/Post-Herpetic
Neuralgia
Somatoform Disorder
Spinal Radiculopathy
Musculoskeletal Gastrointestinal
Gastro-Esophageal Reflux
Disease
Cholecystitis
Pancreatitis
Esophageal Spasm
Esophageal Perforation*
24
DYSPNEA: Cardiac
Dyspnea
Pulmonary Cardiac Other
Pericardial
Effusion
Tamponade
Constriction
Myocardial
Systolic
Dysfunction
Diastolic
Dysfunction
Restrictive
Cardiomyopathy
Valvular
Stenosis
Regurgitation
Sub-Valvular
Disease
Coronary Artery
Disease
Stable Angina
Acute Coronary
Syndrome
Arrhythmia
Atrial Fibrillation
Bradyarrhythmia
Tachyarrhythmia
25
DYSPNEA: Other
Dyspnea
Anemia
Anxiety
Deconditioning
Hyperthyroidism
Metabolic Acidosis
26
ACUTE DYSPNEA
Acute Dyspnea
Presenting within minutes/hours
Cardiovascular
Acute Myocardial Infarction
Tamponade
Respiratory
Pleural
Pneumothorax
Lower Airway
(Wheezing)
Asthma
Chronic Obstructive
Pulmonary Disease
Parenchymal
Pneumonia
Pulmonary Embolism
Upper Airway
(Stridor)
Aspiration
Anaphylaxis
27
EXCESSIVE DAYTIME SLEEPINESS
Excessive Daytime Sleepiness
Inadequate Total
Sleep Time
Insomnia
Sleep Restriction
Circadian Rhythm
Disorder
Poor Sleep Quality
Sleep Apnea
Periodic Limb Disorder
(Rare)
Medical or
Psychogenic
Intrinsic Sleep
Disorders
Narcolepsy
Idiopathic
Hypersomnolence
28
HEMOPTYSIS
Hemoptysis
Massive Hemoptysis
(>100 mL in 24 hours)
Non-Massive
Hemoptysis
Malignancy
Bronchiectasis
Lung Abscess/Mycetoma
Pulmonary Arteriovenous
Malformation
Normal
Chest X-Ray +/- CT
Coagulopathy
Pulmonary Embolism
Acute Bronchitis
Local Abnormality on
Chest X-Ray +/- CT
Diffuse Abnormality on
Chest X-Ray +/- CT
Bronchiectasis
Alveolar Hemorrhage
Syndrome
Infection
Bacterial
Viral
Tuberculosis
Fungal
Malignancy Inflammation
Lupus Erythematosus
Goodpasture's Syndrome
Wegener's Granulomatosis
Pulmonary
Arteriovenous
Malformation
29
HYPOXEMIA
Hypoxemia
Low PO
2
+/- Low O
2
Sat +/- Cyanosis
High Alveolar-Arterial Gradient Normal Alveolar-Arterial Gradient
Right-to-Left Shunt
Ventilation/Perfusion
Mismatch
Airway Disease (Asthma,
COPD)
Vascular (Pulmonary
Embolus)
Parenchymal Disease (+/-
Diffusion Defect)
Low Inspired F
i
O
2
At high altitude
Hypoventilation
Increased PCO
2
Central
Drugs
Coma
Hypothyroidism
Peripheral
Severe V/Q
Mismatch
Status Asthmaticus
Advanced COPD
Parenchymal
Severe Pneumonia
Atelectasis
Intracardiac
Ventricular Septal
Defect
Atrial Septal Defect
Pulmonary
Arteriovenous
Malformation
Chest Wall
Obesity
Neuromuscular
Kyphoscoliosis
Alveolar-Arterial Gradient = P
A
O
2
P
a
O
2
P
A
O
2
= F
i
O
2
(P
B
-P
H20
) (P
a
CO
2
/0.8)
*In Calgary, PB = 660mmHg, Sea level PB = 760mmHg
30
MEDIASTINAL MASS
Mediastinal Mass
Anterior
Thyroid
Thymoma
Teratoma
(Terrible) Lymphoma
Middle Posterior
Neurogenic Tumor
Esophageal Lesion
Diaphragmatic Hernia
Vascular
Aneurysm
Lymphadenopathy
Benign
Malignant
Cystic
Bronchial
Pericardial
Esophageal
31
LUNG NODULE
Lung Nodule
New Nodule
Nodule Present on Chest X-
Ray > 2 Years
Scar
Granuloma
Arteriovenous Malformation
Multiple Nodules Solitary Nodule
Neoplasm
Granuloma
Hamartoma
Pulmonary Embolism
Metastatic Cancer Infection
Fungal
Tuberculosis
Septic Embolism
Inflammation
Rheumatoid
Wegener's
Granulomatosis
Sarcoidosis
Pneumoconioses
Arteriovenous
Malformation
Hereditary
Hemorrhagic
Telangiectasia
Pulmonary
Embolism
32
PLEURAL EFFUSION
Pleural Effusion
If > 1 cm on lateral decubitus x-ray,
do diagnostic thoracocentesis
Exudate
Use Light's Criteria
Transudate
Pulmonary
Infectious
Neoplastic
Inflammatory (Rheumatoid
Arthritis, Systemic Lupus
Erythematosus)
Pulmonary Embolus
Chylothorax
Hemothorax
Gastrointestinal
Ruptured Esophagus
Pancreatitis
Heart Failure
Systolic
Diastolic
Valvular Disease
Low Protein State
Nephrotic
Cirrhosis
Light's Criteria:
Pleural Fluid Protein/Serum Protein > 0.5
Pleural Fluid Lactate Dehydrogenase (LDH)/Serum LDH > 0.6
Pleural Fluid LDH > 2/3 upper serum limit of normal
33
PNEUMONIA TREATMENT FAILURE
Pneumonia Treatment Failure
Wrong Diagnosis
Neoplasm
Vasculitis
Sarcoidosis
Hypertensive Pneumonitis
Endocarditis
Complication of Pneumonia
Empyema
Abscess
Bronchial Obstruction
Superinfections
Wrong Bug/Wrong Drug
Resistance
Fungal
Tuberculosis
Opportunistic Organisms
34
PULMONARY HYPERTENSION
Pulmonary Hypertension
Pulmonary Arterial
Hypertension
Left-Sided Heart
Dysfunction
Systolic
Diastolic
Valvular
Lung Disease and/or
Hypoxemia
Chronic Obstructive Lung
Disease
Interstitial Lung Disease
Sleep Apnea
Idiopathic
Associated with Other
Conditions
Connective Tissue
Disease
Portal Hypertension
Congenital Heart
Disease
Chronic Thromboembolic
Disease
35
SUSPECTED ACID-BASE DISORDER
Suspected Acid-Base Disorder
pH < 7.35
Acidemia
pH < 7.45
Alkalemia
pH 7.35 - 7.45
Normal pH
Mixed Acid-Base Disorder (See
Approach Below; Normal ABG)
Metabolic Acidosis
HCO3- < 24 mmol/L
Respiratory Compensation?
HCO3- : CO2 = 10:12
Respiratory Acidosis
pCO
2
> 40 mmHg
Metabolic Alkalosis
HCO
3
-
> 28 mmol/L
Respiratory Compensation?
HCO3
-
: CO2 = 10:7
Respiratory Alkalosis
pCO
2
< 35 mmHg
Expanded Effective
Arterial Blood Volume
(Conn's Syndrome)
Contracted Effective
Arterial Blood Volume (GI
or Renal Loss of H+)
Normal Anion
Gap
HCO
3
-
Loss
GI (Diarrhea)
Renal (RTA,
Interstitial
Nephritis)
Chronic and
Compensated
HCO3
-
: CO2 = 3:10
COPD
Interstitial Disease
Acute and
Compensated
HCO3
-
: CO2 = 1:10
Asthma
Neuromuscular
Obstruction
Chronic and
Compensated
HCO3
-
: CO2 = 4:10
Pregnancy
Psychogenic
Acute and
Compensated
HCO3
-
: CO2 = 2:10
Hypoxia
Salicylates
Other (Sepsis,
Pulmonary
Embolism)
Diagnosing Mixed Metabolic Disorders in Metabolic Acidosis:
Anion Gap Not ncreased...........Normal AG Acidosis Alone
AAnion Gap = AHCO3
-
......High AG Acidosis Alone
AAnion Gap < AHCO3
-
......Mixed AG Acidosis + Normal AG
AAnion Gap > AHCO3
-
......Mixed High AG Acidosis + Metabolic Alkalosis
High Anion Gap
H
+
Gain
MUDPILES:
Methanol, Uremia,
DKA, Propylene
Glycol, INH/Iron,
Lactate, Ethylene
Glycol, Salicylates
36
37
Hematologic Presentations
Platelets & Vascular System 38
Coagulation Proteins 39
Bleeding Tendency 40
No Bleeding Tendency 41
Prolonged PT (INR), Normal PTT 42
Approach to
Prolonged PT (INR), Prolonged PTT 43
Suspected Deep Vein Thrombosis 44
Suspected Pulmonary Embolus 45
Overall Approach to Anemia 46
Approach to Anemia:
Mean Corpuscular Volume 47
Anemia with Low MCV 48
Anemia with Normal MCV 49
Anemia with Elevated MCV 50
Thrombocytopenia 51
Neutropenia: Decreased Neutrophils Only 52
Neutropenia: Sequestration
& Decreased Production 53
Neutrophilia 54
Polycythemia 55
Lymphadenopathy: Localized 56
Lymphadenopathy: Diffuse 57
Approach to Splenomegaly 58
Fever in the Immunocompromised Host 59
Student Editors
Aravind Ganesh (Section Editor)
Nahbeel Premji
Khaled Ahmed
Ying Wang
Nancy Nixon
Lian Szabo
Faculty Editor
Dr. Lynn Savoie
38
APPROACH TO BLEEDING/BRUISING:
Platelets & Vascular System
Bleeding/Bruising
Platelets Coagulation Proteins Vascular System
Thrombocytopenia
Quantitative Defect
Decreased
Production
Increased
Destruction
Abnormal
Sequestration
Disordered Platelet
Function
Qualitative Defect
Congenital
Connective Tissue
Disorders
Hereditary
Telangiectasia
Acquired
Steroids
Vasculitis
Acquired
Drugs (e.g. ASA)
Renal Disease
Congenital
Rare
Glanzmann
Thrombasthenia
Bernard-Soulier
Syndrome
Others
39
APPROACH TO BLEEDING/BRUISING: Coagulation Proteins
Bleeding/Bruising
Platelets Coagulation Proteins Vascular System
Congenital
Factor VIII Deficiency
Factor IX Deficiency
Von Willebrand's Disease
Other deficiencies
Acquired
Anticoagulation
(Iatrogenic)
Liver Disease
Vitamin K Deficiency
Disseminated
Intravascular Coagulation
40
PROLONGED PTT, NORMAL PT (INR): Bleeding Tendency
Long PTT / Normal PT
Bleeding Tendency No Bleeding Tendency
Congenital Acquired
X-Linked Disorder
Factor VIII Deficiency
(Hemophilia A)
Factor IX Deficiency
(Hemophilia B)
Autosomal
Recessive Disorder
Factor XI Deficiency
Autosomal
Dominant Disorder
von Willebrand's
Disease with a low
Factor VIII
Autoantibodies
Factor VIII Inhibitor
Other Factors (rare)
Drugs
Heparin
41
PROLONGED PTT, NORMAL PT (INR): No Bleeding Tendency
Long PTT / Normal PT
Bleeding Tendency No Bleeding Tendency
Acquired
Lupus-type Inhibitor
Congenital
(Intrinsic Pathway
Factor Deficiency)
Factor XII
Prekallikrein (Fletcher Factor)
High Molecular Weight
Kininogen (Fitzgerald Factor)
42
PROLONGED PT (INR), NORMAL PTT
Normal PTT / Long PT
Sufficient Vitamin K Insufficient Vitamin K
Congenital Clotting Factor
Deficiency Extrinsic Factor
(Factor VII Deficiency)
Vitamin K Deficiency Vitamin K Antagonist
Coumadin (Warfarin) use
Newborn
Hemorrhagic Disease of the
Newborn
Child/Adult
Antibiotics and Poor Nutrition
Fat Malabsorption
43
APPROACH TO PROLONGED PT (INR), PROLONGED PTT
Long PT (INR), Long PTT
Factor Deficiency Inhibitor
Congenital
(Common Pathway)
Factor X
Factor V
Factor II
Fibrinogen
Acquired
Disseminated
Intravascular
Coagulation
Vitamin K Problem Liver Disease
Deficiency
Factor II
Factor VII
Factor IX
Factor X
Antagonist
Coumadin
Drugs
Heparin
Autoantibodies to a
Clotting Factor in the
Common Pathway
(Rare)
Notes:
PT more sensitive to Vitamin K deficiency;
therefore PT used for monitoring Coumadin therapy
PTT more sensitive to heparin; therefore PTT used for
monitoring heparin therapy
44
Suspected Deep Vein Thrombosis (DVT)
Wells, P.S. et al. (2003). Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. New England Journal of Medicine; 349: 1227-1235.
Suspected DVT
Calculate Clinical Probability Score
Low: 5 2 Points High: > 2 Points
Positive
D-Dimer
Negative
D-Dimer
STOP
Positive
Leg U/S
TREAT
Negative
Leg U/S
STOP
Positive
Leg U/S
TREAT
Negative
Leg U/S at 1
Week
STOP
Positive
Venogram
TREAT
Positive
Leg U/S at 1
Week
TREAT
Negative
Venogram
STOP
Negative
Leg U/S
Clinical Probability Score for DVT
Active cancer 1
Paralysis, paresis, recent
immobilization of lower extremity 1
Recently bedridden for >3 days, or
major surgery in last 4 weeks 1
Localized tenderness along
distribution of the deep venous
system 1
Entire leg swollen 1
Calf swelling by >3cm compared
to asymptomatic leg 1
Pitting edema (greater in
symptomatic leg) 1
Collateral, nonvaricose
superficial veins 1
Alternate diagnosis as or more
likely than DVT -2
45
Suspected Pulmonary Embolism (PE)
Wells P.S, et al. (2000). Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the
SimpliRED D-dimer. Thromb Haemost 2003; 83: 416-20.
Writing Group for the Christopher Study Investigators. (2006). Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical
probability, D-Dimer testing, and computer tomography. JAMA;295: 172-179.
Suspected PE
Calculate Clinical Probability Score
Low: 5 4 Points
Negative
D-Dimer
STOP
Positive
D-Dimer
Negative
CT-PE
STOP
Non-
Diagnostic
Positive
CT-PE
TREAT
Negative
Leg U/S
Repeat U/S in
1 Week
Positive
Leg U/S
TREAT
High: > 4 Points
Negative
CT-PE
Non-
Diagnostic
Positive
CT-PE
TREAT
Do
Pulmonary
Angiography
Negative
Leg U/S
Do
Pulmonary
Angiography
Repeat U/S
in 1 Week
Positive
Leg U/S
TREAT
OR
Clinical Probability Score for PE
Clinical signs and symptoms of
DVT (leg swelling and pain with
palpation of the deep veins) 3.0
Alternative diagnosis less
likely than PE 3.0
Heart rate >100bpm 1.5
Immobilization or surgery
in last four weeks 1.5
Previous DVT or PE 1.5
Hemoptysis 1.0
Malignancy (ongoing or
previous 6 months) 1.0
46
Anemia
OVERALL APPROACH TO ANEMIA
Increased RBC Destruction
Increased Reticulocytes,
Increased Unconjugated Bilirubin,
Spherocytes on Smear
Decreased RBC Production
Normal/Decreased Reticulocytes
Blood Loss
Iron Deficiency
B12/Folate Deficiency
Aplastic Anemia
Anemia of Chronic Disease
Marrow Infiltration
Normocytic/
Normochromic
RBCs on Smear
Acute Bleed Chronic Bleed
Congenital
Hemoglobinopathy
Thalassemia
RBC Membrane
Disorder
RBC Metabolism
Disorder
Acquired
Immune
Non-Immune
Any combination
of:
Decreased
Reticulocytes,
MCV, MCH, MCHC,
Serum Iron, Ferritin
Increased
TIBC,
Hypochromic RBCs
47
APPROACH TO ANEMIA: Mean Corpuscular Volume
Anemia
Low Mean Corpuscular
Volume (<80 fL)
Iron Deficiency
Thalassemia
Lead Poisoning
Normal Mean Corpuscular
Volume (80-100 fL)
Bleeding
Hemolysis
Marrow Failure
(e.g. Renal Disease, Liver
Disease, Endocrinopathy,
Chronic Inflammation, Chronic
Infection)
High Mean Corpuscular
Volume (>100 fL)
B12 Deficiency
Folate Deficiency
Drugs
Reticulocytosis
Liver Disease
Hypothyroidism
Myelodysplasia
48
Anemia with Low Mean Corpuscular Volume
ANEMIA WITH LOW MCV
Serum Ferritin
Normal/Increased,
Serum Fe Decreased
Normal/Decreased TIBC
Fe/TIBC >18%
Decreased Heme Synthesis or Decreased Globin Synthesis
Serum Ferritin
Normal/Increased,
Serum Fe and TIBC Normal
MCV/RBC<13,
+/- basophilic stippling,
+/- increased reticulocytes
Decreased Ferritin,
Decreased Fe,
Increased TIBC
Fe/TIBC <18%
MCV/RBC>13
Iron Deficiency (Eg Causes:
Chronic Blood Loss, Occult
Bleed, Malabsorption, Dietary
Deficiency)
Anemia Secondary to
Inflammation
Abnormal
Hemoglobin
HgbE
Increased HgbH,
HgbH inclusions in
RBC
-Thalassemia 2-3
gene deletion
Increased HgbA
2
Increased HgbF
No HgbA
-Thalassemia Major
Increased HgbA
2
Normal HgbA
-Thalassemia Minor
Rule out Iron Deficiency
(Bone Marrow Biopsy)
49
Anemia with normal Mean Corpuscular Volume
ANEMIA WITH NORMAL MCV
Decreased WBCs
Normal/Increased
WBCs
Increased
Reticulocytosis
Primary
Hypersplenism
Secondary
Hypersplenism (e.g.
RA, SLE, PRV,
Chronic Malaria)
Normal
Reticulocytosis
Renal Failure
Inflammation
Cancer
Hypothyroid
Pregnancy
Early Iron Deficiency
Increased
Reticulocytosis
Decreased/Normal
Reticulocytosis
Marrow Aplasia
Marrow Infiltration
Polychromatic Macrocytes,
Normal RBCs
Acute Bleed
Hemolysis
Polychromatic Macrocytes,
RBC Spherocytes,
RBC Fragments
Hemolysis
Microangiopathic Hemolytic
Anemias (MAHA)
Abnormal RBCs
Sickle Cells, Target Cells
Hemoglobinopathy
50
Anemia with elevated Mean Corpuscular Volume (MCV)
ANEMIA WITH ELEVATED MCV
Rule out Reticulocytosis
Oval Macrocytes
Hypersegmented
Neutrophils
Macrocytosis
Target Cells
Normal WBCs
Dysplastic
RBCs in
Rouleaux
Formation
Normal Blood
Smear
Drugs Multiple Myeloma Myelodysplastic
Syndromes
Low Serum B12
Do Schilling Test
Low RBC Folate
Dietary
Deficiency
Malabsorption
Increased
Requirement (e.g.
Pregnancy)
Normal Liver
Function Tests
Rule out B12 and
Folate deficiency
Abnormal Liver
Function Tests
Liver Disease
Malabsorption
corrected with
Intrinsic Factor
Pernicious
Anemia
Malabsorption
not corrected
with Intrinsic
Factor
Small Bowel
Disorder
Pancreatic
Disease
Parasites
51
THROMBOCYTOPENIA
Low Platelet Count
Increased Sequestration Increased Destruction Decreased Production
Splenomegaly
Non-Immune
HELLP Syndrome
TTP/HUS
DIC
Infection
Foreign Surface (e.g.
Prosthetic Heart Valve)
Immune
Ineffective
Megakaryopoiesis
B12 Deficiency
Folate Deficiency
Folate Antagonist
Drugs
Decreased
Megakaryopoiesis
Aplastic Anemia
Toxic Damage (e.g.
Chemotherapy)
Displacement (e.g.
Leukemia, Tumor)
Autoimmune
ITP
SLE
CLL
Alloimmune
HPL-1a
Drugs
Quinidine
Others
Neutropenia
NEUTROPENIA: Decreased Neutrophils Only
Isolated Neutrophil
Decrease
Neutrophils and Other Cell
Lines Decreased
Congenital
Cyclic Neutropenia
Decreased Marrow
Production
Idiopathic
Chronic
Increased
Consumption
Septicemia
Gram Positive
Bacteria
Gram Negative
Bacteria
Decreased Marrow
Production
Systemic Lupus
Erythematosus
Rheumatoid
Arthritis
Medications
Anticonvulsants
Antibiotics
Antithyroid
Antihypertensive
Antirheumatic
Antistroke
Antipsychotic
Antineoplastic
Viral Infection
Epstein-Barr Virus
Cytomegalovirus
Childhood viruses
HIV
Influenza
52
NEUTROPENIA: Squestration & Decreased Production
Neutropenia
Isolated Neutrophil
Decrease
Neutrophils and Other Cell
Lines Decreased
Sequestration
Splenomegaly
Decreased
Production
Marrow Aplasia Medications Marrow Infiltration
Chemotherapy
53
54
NEUTROPHILIA
Infection
Bacterial
Abscess
Viral
Medications
Corticosteroids
Lithium
Epinephrine
Cancer
Solid Tumor (e.g.
Lung, Bladder,
Colon)
Acute Leukemia
Pancytopenia
Anemia
Thrombocytopenia
Blasts on smear
Myeloproliferative
Disorder
Increased Neutrophils
Reactive Neoplasm
Chronic
Myelogenous
Leukemia
WBCs increased
Disorderly WBC
Differential
Increased Platelets
Metamyelocytes,
Myelocytes > Bands
Polycythemia Vera
Increased RBC
Mass
Pruritus/Headaches
(Post-Bathing)
Erythropoietin low
or normal
55
Polycythemia (Erythrocytosis)
POLYCYTHEMIA
Relative
Normal RBC Mass/
Decreased Plasma Volume
Burns
Diarrhea
Dehydration
Idiopathic
True
Elevated RBC Mass
JAK-2 Positive
Low/Normal Erythropoietin,
O2 saturation < 90%,
Splenomegaly, increased PMNs
JAK-2 Negative
Elevated Erythropoietin
Reactive
Polycythemia Vera
High Affinity Hemoglobin
O2 Saturation < 90%
Increased carboxyhemoglobin
Abnormal P450 determination
Smoking, positive Family History,
early onset
Congenital Hemoglobinopathy
Familial Polycythemia
Carboxyhemoglobin
Erythropoietin
Secreting Tumor
O2 Saturation < 90%
Abnormal Abdominal Ultrasound
Renal/Hepatic Cancer
Hypoxia
O2 saturation 90%
Heart Murmur,
Cyanosis without
Pulmonary Disease
Cyanotic Heart Disease
Abnormal Chest X-Ray
Shortness of Breath, Cough,
Smoking, Snoring
Chronic Chest Symptoms
Sleep Apnea
Chronic Pulmonary Disease
56
LYMPHADENOPATHY: Localized
Localized Lymphadenopathy
Reactive Neoplastic
Reactive
Bacterial (e.g.
Pharyngitis,
Cellulitis,
Lymphadenitis)
Stage I-II
Lymphoma
Non-Hodgkin's
Lymphoma
Hodgkin's
Lymphoma
Metastatic
Carcinoma
Nasopharyngeal
Head/Neck
Thyroid
Breast
GI Tract
Melanoma
Inflammatory
Allergy
Acne
Insect Bites
Cervical
Anterior:
Infection (e.g.
Mononucleosis,
Toxoplasmosis)
Posterior:
TB
Lymphoma
Kikuchi Disease
Head/Neck Malignancy
Supraclavicular
Thoracic Malignancy
(Breast, Mediastinum,
Lungs, Esophagus)
Abdominal Malignancy
(Virchow's Node)
Axillary
Infection (Arm,
Thoracic Wall, Breast)
Cancer (In absence of
infection in upper
extremity)
Epitrochlear
(Always pathologic)
Infection (Forearm/
Hand)
Lymphoma
Sarcoidosis
Tularemia
Secondary Syphilis
Inguinal
Leg Infection
Sexually Transmitted
Infection
Cancer
57
Diffuse Lymphadenopathy
LYMPHADENOPATHY: Diffuse
Reactive Neoplastic
Inflammatory
Systemic Lupus
Erythematosus
Sarcoidosis
Rheumatoid
Arthritis
Pseudotumor
Infectious
Tuberculosis
Hepatitis
HIV
Epstein-Barr
Virus
Other Leukemia
Monoclonal
Lymphocytes
on Biopsy
Non-Hodgkin's
Lymphoma
Reed-
Sternberg Cells
on Biopsy
Hodgkin's
Lymphoma
Asymptomatic,
Age > 50
Chronic Lymphocytic
Leukemia (CBC with
Lymphocytosis)
History of
Bleeding, Infection,
Fatigue
Acute Lymphoblastic
Leukemia
(Pancytopenia, WBC
differential includes
Blasts)
58
APPROACH TO SPLENOMEGALY
Splenomegaly
Congestive
Cirrhosis
Thrombus (e.g.
Hepatic, Portal,
Splenic)
Infectious
Bacterial
Viral
Parasitic
Fungal
Infiltrative Inflammatory
Systemic Lupus
Erythematosus
Sarcoidosis
Felty's Disease
Serum Sickness
Hemolytic Disease
Sickle Cell Disease
(in children)
Thalassemia
Congenital
Spherocytosis
Acquired causes
Non-Malignant
Amyloidosis
Gaucher's Disease
Glycogen Storage
Disease
Malignant
Lymphoma
Leukemia
Polycythemia Rubra
Vera
Essential
Thrombocytosis
Myeloid Metaplasia
Myelofibrosis
Tumors
59
Fever in the Immunocompromised Host
Cellular Defect
FEVER IN THE IMMUNOCOMPROMISED HOST
Structural Defect
Asplenia/Hyposplenism
Protein Defect
Encapsulated Bacteria
Bacteremia/Septic
Shock
Cell Mediated Immunity
T-Cells affected
Chronic Steroid use
Organ Transplant recipients
HIV
Pneumonia
Central Nervous System
Infection
Disseminated Herpes Zoster
Aspergillus or Candida
Infection
Pneumocystis jirovecii
(carnii)
Neutropenia or
Neutrophil Dysfunction
Aphthous Ulceration
Perirectal Infection
Abscess Formation
Soft Tissue and Visceral
Infection
Periodontal Disease
Complement Deficiency
Bacteremia/Septic Shock
Pneumonia
Encapsulated Bacteria
(Streptococcus pneumoniae,
Haemophilus influenzae,
Neisseria spp.)
Systemic Lupus
Erythematosus
Hypogammaglobulinemia
Recurrent Sinusitis
Pneumonia
Bronchitis
Chronic Diarrhea
Encapsulated Bacterial
Diarrhea (e.g. Haemophilus
influenzae)
Giardia Infection
60
61
Gastrointestinal Presentations
Abdominal Distention: Ascites 63
Abdominal Distention: Bowel Dilatation 64
Abdominal Distention: Other Causes 65
Acute - Diffuse 66
Acute - Localized 67
Chronic - Constant 68
Chronic - Crampy/Fleeting 69
Chronic - Post-Prandial 70
Anorectal Pain 71
Acute Diarrhea 72
Stool Incontinence 73
Chronic Diarrhea:
Steatorrhea & Large Bowel 74
Chronic Diarrhea: Small Bowel 75
Constipation (Adult): Altered Bowel
Function & Idiopathic 76
Constipation (Adult): Secondary Causes 77
Constipation (Pediatric) 78
Dysphagia 79
Mouth Disorders: Adult & Elderly 80
Mouth Disorders: Pediatric 81
Nausea & Vomiting:
Gastrointestinal Disease 82
Nausea & Vomiting:
Other Systemic Disease 83
Nausea & Vomiting
with Associated Symptoms 84
Upper Gastrointestinal Bleed
(Hematemesis/Melena) 85
Lower Gastrointestinal Bleed 86
Weight Loss 87
62
Weight Gain 88
Hepatomegaly 89
Jaundice 90
Elevated Liver Enzymes 91
Liver Mass 92
Abdominal Mass 93
Student Editors
James Lee (Section Editor)
Michael Prystajecky
Shabaz Syed
Stacy Cormack
Shaina Lee
Matt Linton
Khaled Ahmed
Ying Wang
Mia Steiner
Beata Komierowski
Daniel Shafran
Robbie Sidhu
Faculty Editor
Dr. Sylvain Coderre
Dr. Chris Andrews
63
Abdominal Distention
Ascites
High Albumin Gradient
(SAAG)
> 11 g/L serum-fluid albumin
ABDOMINAL DISTENTION: Ascites
Bowel Dilatation Other Causes
Low Albumin Gradient
(SAAG)
< 11 g/L, serum-fluid albumin
Portal Hypertension
Cirrhosis
Alcoholic Hepatitis
Budd-Chiari Syndrome
Cardiac
Peritoneal
Carcinomatosis
Infection (Neutrophils >
250/cc)
Other Causes
Pancreatitis
Serositis
Nephrotic Syndrome
64
ABDOMINAL DISTENTION: Bowel Dilatation
Ascites Bowel Dilatation Other Causes
Mechanical Obstruction
Adhesions
Volvulus
Malignancy
Herniation
Pseudo-Obstruction
Paralytic Ileus
Clostridium difficile
Peritonitis
Post-surgical Hypothyroidism
Acute Colonic Chronic Intestinal
Toxic Megacolon OgiIvie's Syndrome
Trauma/Surgery
Medical Conditions (e.g.
Myocardial Infarction,
Congestive Heart Failure)
Drugs
Retroperitoneal
Hemorrhage/Malignancy
Myopathic
Scleroderma
Familial Myopathy
Neuropathic
Enteric (e.g. Amyloidosis,
Paraneoplastic,
Narcotics)
Extrinsic (e.g. Multiple
Sclerosis, Spinal Injury,
Stroke)
65
ABDOMINAL DISTENTION: Other Causes
Ascites Bowel Dilatation Other Causes
Pelvic Mass
Pregnancy
Fibroids
Ovarian Mass
Bladder Mass
Malignancy
Obesity
Feces/Flatus
Constipation
Irritable Bowel
Syndrome
Carbohydrate
Malabsorption
Diet (Lactose
Intolerance)
Chronic Obstruction
Organomegaly
Hepatomegaly
Splenomegaly
Hydronephrosis
Renal Cysts
Aortic Aneurysm
66
Acute Abdominal Pain (< 72 hours)
ABDOMINAL PAIN (ADULT): Acute - Diffuse
Look For Surgical Abdomen
Upper Quadrant: R/O Cardiac, Pulmonary, Renal, Musculoskeletal Causes
Lower Quadrant: R/O Genitourinary Causes
Diffuse Localized
Peritonitic
Viscus Perforation
Abdominal Aortic
Aneurysm Rupture
Pancreatitis
Bowel Obstruction
Bowel Infiltration
Non-Peritonitic
Gastroenteritis
Irritable Bowel
Syndrome
Constipation
Metabolic Disease
(e.g. Diabetic
Ketoacidosis)
Mesenteric Ischemia
Mesenteric Thrombus
Sickle Cell Anemia
Musculoskeletal
Trauma
67
ABDOMINAL PAIN (ADULT): Acute - Localized
Acute Abdominal Pain (< 72 hours)
Evaluate for surgical abdomen
Upper Quadrant: rule out Cardiac, Pulmonary, Renal, Musculoskeletal causes
Lower Quadrant: rule out Genitourinary causes
Diffuse Localized
Non-Peritoneal Peritoneal Peritoneal
Perforated Ulcer
Pancreatitis
Cholecystitis
Splenic Rupture
Non-Peritoneal
Irritable Bowel
Syndrome
Psoas Abscess
Urinary Tract Infection
Ureteric Colic
Upper Quadrant Lower Quadrant
Right Upper
Quadrant
Biliary Colic
Hepatitis
Hepatic Abscess
Bowel Obstruction
Pyelonephritis
Epigastric
Gastritis
Esophageal Rupture
Biliary Colic
Left Upper Quadrant
Splenic Infarct
Splenic Abscess
Splenic Rupture
Bowel
Appendicitis
Diverticulitis
Incarcerated Hernia
Pelvic/Adnexal
Ectopic Pregnancy
Ovarian Torsion
Pelvic Inflammatory
Disease
Salpingitis
68
ABDOMINAL PAIN (ADULT): Chronic - Constant
Chronic Abdominal Pain
Crampy/Fleeting
Recurrent abdominal pain? Consider tumor
Upper Quadrant/Epigastric? Consider cardiac causes
Lower quadrant? Consider genitourinary causes
Post-Prandial Constant
Upper Quadrant
Gastroesophageal Reflux
Disease
Liver Distention (e.g.
Hepatomegaly, Tumor, Fat)
Chronic Pancreatitis
Pancreatic Tumor
Gastric Cancer
Splenic (e.g. Abscess,
Splenomegaly) very rare
Lower Quadrant
Crohn's Disease
Gynecologic (e.g. Tumor,
Endometriosis)
Any Location/Diffuse
Ascites
Muscle Wall
Neuropathic Pain
Somatization
69
ABDOMINAL PAIN (ADULT): Chronic - Crampy/Fleeting
Crampy/Fleeting
Upper Quadrant
Biliary Colic/Cholelithiasis
Choledocholithiasis
Sphincter of Oddi
Dysfunction
Renal Colic
Lower Quadrant
Bloating (e.g. Celiac Disease,
Lactose Intolerance, Renal
Colic
Irritable Bowel Syndrome
Bowel Obstruction (e.g.
Adhesions, Crohn's,
Volvulus, Neoplasm, Hernia)
70
ABDOMINAL PAIN (ADULT): Chronic - Post-Prandial
Crampy/Fleeting
Upper Quadrant
Biliary Colic/Cholelithiasis
Disease
Peptic Ulcer Disease/
Dyspepsia
Gastric Cancer
Chronic Pancreatitis
Lower Quadrant
Obstructing Colon Cancer
Bowel Obstruction (e.g.
Adhesions, Crohn's,
Volvulus, Neoplasm, Hernia)
Atherosclerosis
71
ANORECTAL PAIN
Anorectal Pain
Exclude: Poor Hygiene, Dietary, Anal Trauma
Internal Lesion External Lesion
Proctitis Other Dermatologic
Anorectal
Disease
Fissure
Fistula/Abscess
(Crohn's)
Hemorrhoid
Dermatitis
Psoriasis
Malignancy
Solitary Rectal
Ulcer
Inflammation
Infection
(Including
Sexually
Transmitted)
Diagnosis of
Exclusion
Proctalgia
72
ACUTE DIARRHEA
Acute Diarrhea
> 2-3 loose stools/day, >175 - 235 g/day; >48 hours, < 14 days
Infectious Dietary Inflammatory Ischemic
Bloody
Ulcerative Colitis
Crohn's Colitis
Non-Bloody
Crohn's leitis
Crohn's Colitis
Nausea/Vomiting
Predominant
Bacillus cereus
Staphylococcus aureus
Diarrhea Predominant
Watery/Large Volume
(Small Bowel)
Viral
Bacterial (e.g. C.
perfringens, V. cholerae, E.
coli, Salmonella, Yersinia)
Parasitic (e.g. Giardia)
Drugs (Antibiotics,
Laxatives, Antacids)
Toxins
Bloody/Pain/Small
Volume/Urgency
(Large Bowel)
Bacterial (e.g. E. coli, C.
difficile, Salmonella,
Campylobacter, Shigella)
Parasitic (e.g. E. histolytica)
73
Stool Incontinence
STOOL INCONTINENCE
Intact Pelvic Floor Affected Pelvic Floor
Chronic Constipation
Stool Incontinence
Encopresis
Neurological
Conditions
Age-Related (e.g.
Dementia, Strokes)
Neuropathy (e.g.
Diabetes, Congenital
Megacolon,
Hirschsprung's
Disease)
Multiple Sclerosis
Tumors/Trauma (e.g.
Brain, Spinal Cord,
Cauda Equina)
Diarrheal Conditions
Inflammatory Bowel
Disease
Irritable Bowel
Syndrome
Chronic Laxative Use
Stress and Emotional
Problems
Congenital Anorectal
Malformation
Nerve/Sphincter Damage
Vaginal Delivery
Rectal Prolapse
Severe Hemorrhoid
Trauma/Surgery
Surgery; Anorectal, Prostate,
Bowel
Pelvic Fracture
Pelvic Irradiation
74
CHRONIC DIARRHEA: Steatorrhea & Large Bowel
Chronic Diarrhea
> 3 Loose Stools/Day, > 14 Days
Exclude Chronic Inflammation
Steatorrhea
Oily/Foul/Hard to Flush
Large Bowel
Small Volume/Bloody/Painful/
Tenesmus/Urgency
Small Bowel
Large Volume/Watery
Secretory
Villous Adenoma
Colon Cancer
Microscopic Colitis
Malabsorptive
Inflammatory
Inflammatory Bowel
Disease
Radiation Colitis
Ischemic Colitis
Primary
Malabsorption
Celiac Disease
Mucosal Disease
leal Crohn's
Disease
Motility
Irritable Bowel
Syndrome
Hyperthyroid
Maldigestive
Pancreatic
Insufficiency
Secondary
Malabsorption
Bacterial
Overgrowth
Liver Cholestasis
Mesenteric
Ischemia
Short Bowel/
Resection
75
CHRONIC DIARRHEA: Small Bowel
Chronic Diarrhea
> 3 Loose Stools/Day, > 14 Days
Exclude Chronic Inflammation
Steatorrhea
Oily/Foul/Hard to Flush
Large Bowel
Small Volume/Bloody/Painful/
Tenesmus/Urgency
Small Bowel
Large Volume/Watery
Secretory
Disordered Motility
Diabetic Neuropathy
Hyperthyroidism
Osmotic
Magnesium, Phosphate,
Sulfate
Carbohydrate Malabsorption
Lactose Intolerance
Tumors Mucosal
Crohn's Disease
Celiac Disease
Chronic Inflammation
Whipple's Disease
Mucosal
Gastrinoma/VIPoma
Carcinoid Syndrome
Mastocytosis
Neoplastic
Adenocarcinoma
Lymphoma
76
CONSTIPATION (ADULT): Altered Bowel Function &
Idiopathic
Infrequency (< 3 bowel movements/week)?
Sensation of blockage or incomplete evacuation? Straining?
Constipation
Altered Bowel Function Severe Idiopathic Secondary Causes
Irritable Bowel Medications
Neurally Active
Medications (e.g.
Opiates, Anti-
Hypertensives)
Cation Related (e.g.
Iron, Aluminum,
Calcium,
Potassium)
Anticholinergic (e.g.
Antispasmodics,
Antidepressants,
Antipsychotics)
Colonic Inertia Outlet Delay
Pelvic Floor
Dyssynergia
Diet/Lifestyle
Fibre
Calories
Fluid
Exercise
Psychosocial
77
Infrequency (< 3 bowel movements/week)?
Sensation of blockage or incomplete evacuation? Straining?
CONSTIPATION (ADULT): Secondary Causes
Constipation
Altered Bowel Function Severe Idiopathic Secondary Causes
Neurogenic Non-Neurogenic
Peripheral
Hirschsprung's Disease
Autonomic Neuropathy
Pseudo-obstruction
Central
Multiple Sclerosis
Parkinson's Disease
Spinal Cord/Sacral/
Cauda Equina Injury
Metabolic
Hypothyroidism
Hypokalemia
Hypercalcemia
Colorectal Disease
Colon Cancer
Colonic Stricture
(Inflammatory Bowel
Disease and
Diverticular Disease)
78
CONSTIPATION (PEDIATRIC)
Constipation
Infrequent bowel movements? Hard, small
stools? Painful evacuation? Encopresis?
Older Child Neonate/Infant
Neurologic
Hirschsprung's
Disease
Spinal Cord Lesions
Amyotonia
Congenita
Guillain-Barr
Syndrome
Neurologic
Hirschsprung's
Disease
Imperforate Anus
Anal Atresia
Intestinal Stenosis
Intestinal Atresia
Dietary/Functional
Insufficient Bulk/
Fluid
Withholding
Painful (e.g.
Fissures)
Anatomic
Bowel Obstruction
Pseudo-obstruction
Dietary/Functional
Insufficient Volume/
Bulk
79
DYSPHAGIA
Dysphagia
If heartburn present - Consider
GERD
Oropharyngeal Dysphagia
Immediate Difficulty
Difficulty initiating swallowing?
Choking? Nasal Regurgitation?
Esophageal Dysphagia
Delayed Difficulty
Food Sticks Seconds Later / Further Down?
Mechanical
Obstruction
Solids Only
Neuromuscular/
Toxic/Metabolic
Myasthenia Gravis
CNS Tumors
Cerebrovascular
Accident
Multiple Sclerosis
Amyotrophic Lateral
Sclerosis
Polymyositis
Functional
Xerostomia
Motor Disorder
Solids and/or Liquids
Structural
Tumors
Zenker's
Diverticulum
Foreign Body
Progressive
Symptoms
Peptic Stricture
Esophageal Cancer
Intermittent
Symptoms
Esophageal Spasm
Progressive
Symptoms
Scleroderma
Achalasia
Diabetic Neuropathy
Intermittent
Symptoms
Esophageal Stricture
Schatzki Ring
Esophageal Web
80
MOUTH DISORDERS: Adult and Elderly
No Color Change
Chronic Liver
Disease
Sjogren's Syndrome
Acromegaly
Amyloidosis
Psoriasis
Gingival
Hyperplasia
Dry Mouth
Lighter (White) Darker (Red)
Gingivitis
Kawasaki Disease
(Strawberry
Tongue)
Other Gum Disease
Mucocele
Allergic Reaction
Ulcerating Non-Ulcerating
Mucous Membrane Teeth
GERD (Dissolves
Enamel)
Sjogren's Syndrome
(Dental Caries)
Mouth Disorders
Consider oral manifestations of systemic disease
Neoplastic
Leukoplakia
Squamous Cell
Carcinoma
Non-Neoplastic
Candidiasis
Lichen Planus
Anemia
Gastrointestinal
Crohn's Disease
Ulcerative Colitis
NSAIDs
Other
Canker Sore
Cold Sore
Anemia
Langerhan's Cell
Histiocytosis
Wegener's Disease
Sarcoidosis
Drug Induced
Sexually
Transmitted
Infection
81
MOUTH DISORDERS: Pediatric
Mouth Disorders
Teeth Mucous Membranous
Teething
Painful Non-Painful
Other
Gum Disease (e.g.
Gingivitis)
Hand, Foot, and Mouth
Disease (Coxsackie Virus)
Streptococcal Throat
Infection
Canker Sore
Herpes Simplex Virus
Inflamed Papillae (e.g.
Burn)
Non-Inflammatory
Impetigo
Mucocele
Candidiasis
Inflammation
Allergic Reaction
Gastrointestinal
Crohn's Disease
Ulcerative Colitis
82
NAUSEA AND VOMITING: Gastrointestinal Disease
Nausea and Vomiting
Gastrointestinal Disease Other Systemic Disease
Upper Gastrointestinal Hepatobiliary
Acute Hepatitis
Acute Cholecystitis
Cholelithiasis
Choledocholithiasis
Acute Pancreatitis
Lower Gastrointestinal
Acute
Infectious
Gastroenteritis
Gastric/Duodenal
Obstruction
Gastric Volvulus
Chronic
Gastroesophageal
Reflux Disease
Gastroparesis
Acute
Infectious
Gastroenteritis
Acute Appendicitis
Small/Large Bowel
Obstruction
Mesenteric Ischemia
Acute Diverticulitis
Chronic
Inflammatory Bowel
Disease
Colonic Neoplasm
83
Nausea and Vomiting
NAUSEA AND VOMITING: Other Systemic Disease
Endocrine/Metabolic
Pregnancy
Diabetes
Uremia
Hypercalcemia
Addison's Disease
Thyroid Disease
Other
Sepsis (e.g.
Pyelonephritis,
Pneumonia)
Radiation Sickness
Acute Myocardial
Infarction
Drugs/Toxins
Chemotherapy
Antibiotics
Ethanol
Carbon Monoxide
Heavy Metal
Nicotine
Central Nervous
System
Gastrointestinal Disease Other Systemic Disease
High Intracranial
Pressure
Hemorrhage
Meningitis
Infarction
Malignancy
Head Trauma
Vestibular
(Inner Ear)
Ear Infection
Motion Sickness
Vestibular Migraine
Mnire's Disease
Self-Induced (Bulimia)
Cyclic Vomiting
Psychogenic
Psychiatric
84
Nausea and Vomiting
With Associated Symptoms
NAUSEA AND VOMITING WITH ASSOCIATED SYMPTOMS
Abdominal Pain No Abdominal Pain
Drugs (e.g. Alcohol Withdrawal)
Migraine
Pregnancy
Vestibular
Metabolic
Ketoacidosis
Uremia
Cerebellar Hemorrhage
Relieved by Vomiting Not Relieved by Vomiting
Small Bowel Obstruction
Gastric Outlet Obstruction
Myocardial Infarction
Gall Bladder Disease
Hepatitis
Pancreatitis
85
Acute Hematemesis
If melena, 5-10% colorectal/small bowel.
Exclude bleeding disorder
Other Causes
UPPER GASTROINTESTINAL BLEED
(HEMATEMESIS/MELENA)
Retching?
Mallory Weiss Tear
Blood in vomitus?/Black, tarry stools?
Esophagitis/Gastritis
xEsophogastric
varices
Portal Hypertension
(15%)
xHelicobacter pylori
xNSAIDS
xStress (in ICU setting)
xGastric acid hypersecretion (e.g.
Zollinger-Ellison)
(55%)
xBenign
xMalignant
Tumors
86
Lower Gastrointestinal Bleed
Angiodysplasia
(20 30%)
Diverticulosis
(30 50%)
Other Causes
LOWER GASTROINTESTINAL BLEED
Colorectal Cancer
Anorectal
(especially < 50
years of age)
Other
Blood present in stool? Fecal Occult Blood test
positive?
xHemorrhoids
xFissures
xEnterocolitis
xIschemia
xInflammatory
xInfectious
xSmall bowel tumor
87
WEIGHT LOSS
Environmental, Social and
Functional Causes
Isolation/Loneliness
Poverty
Elder Abuse
Psychological/Psychiatric
Causes
Depression
Dementia
Somatic Causes
Increased Protein/Energy
Requirements (e.g. Post-
Surgical, Infections, Trauma,
Burns, Decubitus Ulcers)
Malabsorption Syndromes
(e.g. Crohn's Disease,
Ulcerative Colitis, Celiac
Disease)
Cancer
Hyperthyroidism
Hypothyroidism
Diabetes Mellitus (Poorly
Controlled)
Autoimmune Disorders (e.g.
Giant Cell Arteritis,
Polymyalgia Rheumatica)
Chronic Cardiac/Respiratory
Distress
Chronic Renal Failure
Adrenal Insufficiency
Adverse Drug Side Effects
Causing Anorexia
Weight Loss
88
WEIGHT GAIN
Weight Gain
Increased Intake
Dietary
Social/Behavioural
Iatrogenic (e.g. Medications)
Neurogenic/Genetic
Depression
Dementia
Decreased Expenditure
Sedentary Lifestyle
Smoking Cessation
Hypothalamic/Pituitary
Hypothalamic Syndrome
Growth Hormone Deficiency
Gonadic
Polycystic Ovarian
Syndrome
Hypogonadism
Other Causes
Cushing's Disease
Hypothyroidism
89
HEPATOMEGALY
Hepatomegaly
Rule Out concurrent Splenomegaly and Jaundice
Inflammatory
Alcoholic Hepatitis
Autoimmune Hepatitis
Drug Induced Hepatitis
Sarcoidosis
Histocytosis X
Primary Sclerosis
Cholangitis
Primary Biliary
Cirrhosis
Infiltrative Congestive
Right Heart Failure
Budd-Chiari Syndrome
Infectious
Hepatitis A, B, C
Mononucleosis
Tuberculosis
Bacterial Cholangitis
Abscess
Schistosomiasis
Malignant
Primary Carcinoma
Metastases
Lymphoma
Leukemia
Polycythemia
Multiple Myeloma
Non-Malignant
Fatty Liver
Cirrhosis
Cysts
Hemochromatosis
Wilson's Disease
Amyloidosis
Myelofibrosis
90
Hepatocellular
Cholestatic
JAUNDICE
Jaundice
Pre-Hepatic
Unconjugated Hyperbilirubinemia
Hepatic
Conjugated Hyperbilirubinemia
Post-Hepatic
Usually has Duct Dilatation on Ultrasound
Intraductal
Obstruction
Gallstones
Biliary Stricture
Cholangiocarcinoma
Primary Sclerosing
Cholangitis
Decreased Hepatic
Uptake
Sepsis
Drugs (e.g.
Rifampin)
Decreased
Conjugation
Gilbert's Syndrome
Crigler-Najjar
Syndromes (I and II)
Biliary Duct
Compression
Malignancy
Metastases
Pancreatitis
Increased
Production
Hemolysis
Ineffective
Erythropoiesis
Hematoma
See Elevated Liver Enzymes scheme
91
Common Bile Duct
Stone
Pancreatic Cancer
Bile Duct Atresia/
Stricture
Primary Sclerosing
Cholangitis
Bile Duct Cancer
Elevated Liver Enzymes
ELEVATED LIVER ENZYMES
Hepatocellular
ALT, AST > ALP
Cholestatic
ALP > ALT, AST
Intrahepatic
Bile Ducts Normal on U/S
Extrahepatic
Bile Ducts Dilated on U/S
Alcohol/Drugs
* may cause severe elevation in ALT (>15x ULN)
Autoimmune
Primary Biliary
Cirrhosis
Primary Sclerosing
Cholangitis
Any hepatocellular cause may present as cholestatic
Viral
Bacterial
Granulomatous
Disease
Infection/
Inflammation
Infiltrative
Malignancy
Amyloidosis
Viral/Autoimmune
Hepatitis B*
Hepatitis C*
Autoimmune
Hepatitis*
Metabolic
Hemochromatosis
1-Antitrypsin
Deficiency
Wilson's Disease
Other
NAFLD/NASH
Alcohol
Pregnancy*
Drugs/Toxins*
Ischemia*
Malignant
Infiltration*
92
LIVER MASS
Malignant Benign
Cystadenoma
Polycystic/Simple
Hydatid Cyst
Malignant
Cystadenocarcinoma
Benign
Cystic Solid
Liver Mass
Secondary
Malignancy
Metastases (e.g. Lung,
Colon, Breast)
Primary Malignancy
Hepatocellular
Carcinoma
Cholangiocarcinoma
Infectious
Abscess
Proliferative
Hemangioma
Focal Nodular
Hyperplasia
Adenoma
93
ABDOMINAL MASS
Exclude pregnancy/hernia/abdominal wall mass
Abdominal Mass
Neoplastic
Gastrointestinal Tumors (e.g.
Colonic, Gastric, Pancreatic)
Gynecologic Tumors (e.g. Ovarian,
Uterine)
Lymphoma/Sarcoma
Organomegaly
Spleen
Liver
Kidneys (e.g. Cysts, Cystic Renal
Cell Carcinoma, Hydronephrosis)
Other Causes
Pseudoneoplastic
Pancreatic Pseudocyst
Pulsatile
Vascular (Abdominal Aortic
Aneurysm)
94
95
Renal Presentations
Acute Renal Failure 96
Chronic Renal Failure 97
Generalized Edema 98
Hypertension 99
Hematuria 100
Proteinuria 101
Hyponatremia 102
Hypernatremia 103
Hypokalemia 104
Hyperkalemia: Intracellular Shift 105
Hyperkalemia: Reduced Excretion 106
Metabolic Acidosis: Elevated Anion Gap 108
Metabolic Acidosis: Normal Anion Gap 109
Metabolic Alkalosis: Contracted EABV 110
Metabolic Alkalosis: Expanded EABV 111
Increased Urinary Frequency 112
Polyuria 113
Dysuria 114
Nephrolithiasis 115
Urinary Tract Obstruction 117
Renal Mass: Solid 118
Renal Mass: Cystic 119
Scrotal Mass 120
Student Editors
Maria Wu (Section Editor)
Eric Sy
Vera Krejcik
Marc Chretien
Becky Kennedy
Mollie Ferris Faculty Editors
Keith Lawson Dr. Kevin McLaughlin
Vanessa Millar Dr. Andrew Wade
Derrick Chan Dr. Sophia Chou
96
ACUTE RENAL FAILURE
Acute Renal Failure
Consider urinalysis, renal U/S, fractional excretion of sodium (FeNa)
Pre-Renal
j
FeNa < 1%, bland urine sediment
Renal
Abnormal urinalysis
Post-Renal
Evidence of obstruction
Bladder Obstruction
Ureter Obstruction
Urethral Obstruction
Other
NSAIDs
ACE Inhibitors
Low Cardiac Output
Heart Failure
Cardiogenic Shock
Obstructive Shock
Volume Depletion
Hemorrhage
Losses (GI, Renal)
Third Spacing
Poor Intake
Decreased Vascular
Resistance
Cirrhosis
Sepsis
Drugs
Distributive Shock
Drugs (NSAIDs, -lactams)
Infection
Immunological (SLE)
Interstitial/
Obstructive
Acute Tubular Necrosis
i
Granular/epithelial casts
FeNa < 2%
Ischemia
Toxins
Pigments (Hgb or Mgb)
Vascular Causes
Hemolytic Uremic
Syndrome
Thrombotic
Thrombocytopenic
Purpura
Vasculitis
Renal Vein Thrombosis
Renal Artery Stenosis
Acute Glomerulonephritis
ANCA-associated
Glomerulonephritis (Polyarteritis
Nodosa, Wegener's)
Anti-glomerular Basement
Membrane Antibody Disease
(Goodpasture's and anti-GBM
Nephritis)
Immune-complex Deposition (Lupus
Nephritis, Post-Streptococcal
infection, Cryoglobulinemic
Glomerulonephritis)
IgA Nephropathy
Acute Interstitial Nephritis
Leukocytes/leukocyte casts,
+/- eosinophils in urine
Tubular Obstruction
Urine paraprotein?
Urate or Ca oxalate crystals?
Cast Nephropathy
Urate
Calcium Oxalate
j most common cause of ARF in the outpatient setting
i
most common intra-renal cause of ARF
97
CHRONIC RENAL FAILURE
* Diabetes and hypertension are the two most common causes of CRF
Pre-Renal
Evidence of Renovascular Disease
(Bruits, Radiologic)
Drugs + Renal Artery
Stenosis
Decreased Effective Arterial
Blood Volume (End-Stage
Heart Failure, Liver Disease)
Atheroembolism
Renal
Post-Renal
Bland Urine Sediment/Evidence of
Obstruction (Hydronephrosis)
Nephrolithiasis
Prostatic Hypertrophy
Tumor
Consider acute or acute on chronic in the differential diagnosis
Tests: Urinalysis, Creatinine, Renal U/S
Glomerular
Protein Excretion > 500 mg/day
Dysmorphic Red Cells/Casts
Diabetes*
Hypertension*
Glomerulonephritis
Focal Glomerulosclerosis
Reduced Nephron Mass
(Secondary to Acute
Glomerulonephritis or Renal
Hypoplasia)
Tubular
Positive family history
Evidence of cystic disease
on ultrasound
Autosomal Dominant
Polycystic Kidney Disease
(ADPKD)
Autosomal Recessive PKD
(ARPKD)
Nephronophthisis (NPH)
Other inherited renal disease
Tubulo-interstitial
Leukocytes casts,
May have bland urine
Drugs
Infections
Reflux Nephropathy
Immunological
Metabolic
Hematological
98
Overfill
Expanded Effective Arterial Blood Volume
Primary Renal Sodium Retention
GENERALIZED EDEMA
Generalized Edema
Underfill
Decreased Effective Arterial Blood Volume
Secondary Renal Sodium Retention
Non-steroidal Anti-inflammatory
Drugs
Signs of Ventricular Failure
Altered Volume/Capacitance
Ratio
Pregnancy
Portal Hypertension
Altered Starling Forces
Increased Interstitial
Oncotic Pressure
Myxedema (Hypothyroid)
Malignancy
Increased Capillary
Permeability
Inflammation
Sepsis
Acute Respiratory
Distress Syndrome
Burns/Trauma
Allergy
Decreased Capillary
Oncotic Pressure
Low Serum Albumin
Nephrotic Syndrome
Cirrhosis
Protein-Losing
Enteropathy
Increased Capillary
Hydrostatic Pressure
Right-sided Heart Failure
(Cor Pulmonale)
99
HYPERTENSION
Hypertension
Volume Dependent
Secondary (5%)
Onset age < 20 or > 50 years.
No family history. Hypertensive
urgency, Refractory hypertension.
Systemic Vascular
Resistance
(Vasoconstrictive)
Primary (Essential) (95%)
Onset between age 20 and 50.
Positive family history.
No features of secondary hypertension.
Long-Standing
Uncontrolled
Drug Withdrawal
Mislabelled
Repeatedly normal blood pressure
when taken at home, work
or using an ambulatory monitor.
White Coat Hypertension
Masked Hypertension
Definition of hypertension:
Systolic BP < 140mmHg or Diastolic BP < 90mmHg
solated systolic hypertension in the elderly < 160mmHg
Diabetes mellitus/Chronic kidney disease < 130/80mmHg
Renal Parenchymal
Disease
Elevated serum Cr,
Abnormal urine analysis,
Epigastric systolic-diastolic bruit.
Glomerulonephritis
Acute Kidney Injury
Bilateral Renal Artery
Stenosis
Medications
NSAIDs
Oral
Contraceptive
Pill
Mineralocorticoid
Excess
Hypokalemia,
Metabolic alkalosis,
High TTKG.
Primary
Hyperaldosteronism
Licorice
Liddle's Syndrome
Angiotensin II
Excess
Asymmetric kidney size on
ultrasound +/- epigastric
systolic-diastolic bruit.
Unilateral Renal
Artery Stenosis
Radio-femoral
delay
+/- features
of coarctation
Aortic
Coarctation
Catecholamine
Excess
Episodic headache,
sweating & tachycardia.
Pheochromocytoma
100
HEMATURIA
If there are no localizing clinical features and the hematuria is microscopic, investigate the upper urinary tract in patients < 40 years
(KUB X-ray & ultrasound). Patients > 40 yrs and patients with macroscopic hematuria should also have cystoscopy.
Hematuria
Exclude Red Supernatant
(i.e. is the sediment or supernatant red after centrifugation?)
If supernatant red consider heme-positive causes (e.g. hemoglobinuria or
myoglobinuria) or heme negative causes (e.g. bacteriuria or drugs)
Extraglomerular (85%)
Isomorphic RBCs, no casts,
Proteinuria <500 mg/day, blood clots
Glomerular (15%)
Dysmorphic RBCs, RBC casts
Isolated
IgA Nephropathy
(Microscopic/Gross
Hematuria)
Thin Basement
Membrane
(Microscopic
Hematuria)
Alport Syndrome
(Family History
Gross Hematuria)
Nephrolithiasis
Flank Pain
History of Trauma
Urine Flow Related
Symptoms
Incontinence
Trauma (e.g. Foley
Insertion)
Tumors (e.g.
Smokers +/-
Imaging/Urine
Cytology
Benign Prostatic
Hypertrophy
Calculi
With Proteinuria
Urinary Tract
Infection
Urine analysis with
Leukocytes +/- Nitrites with
bacteria on microscopy
Refer to Proteinuria
scheme
101
PROTEINURIA
Proteinuria (> 150 mg/day)
Persistent
Orthostatic
<50 mg of Protein in urine for
overnight (8 hour) collection
Transient
Resolves spontaneously on repeat testing
Overflow
Negative urine dipstick for Albumin,
Urine Paraprotein present
Glomerular
Positive urine dipstick for Albumin
Tubular
Negative urine dipstick for Albumin,
No urine Paraprotein
Multiple Myeloma
Myoglobinuria
Active Urine Sediment
Dysmorphic Red Cells and Casts
Non-Active Urine Sediment
No Red Cell Casts
Secondary
Systemic disease
Diabetes
Hypertension
Amyloidosis
Primary
Disease limited to kidney
IgA Nephropathy
Membranoproliferative
Glomerulonephritis
Mesangial Proliferative
Glomerulonephritis
Secondary
Systemic disease
Anti-glomerular Basement
Membrane Disease
Wegener's
Granulomatosis
Systemic Lupus
Erythematosus
Henoch-Schonlein
Purpura
Post-Infectious
Glomerulonephritis
Primary
Disease limited to kidney
Membranous
Nephropathy
Minimal Change Disease
Focal Segmental
Glomerulosclerosis
102
HYPONATREMIA
Hyponatremia
Serum Sodium < 135 mmol/L
Artifactual
Serum Osmolality not
reduced >280 mosm/L
Hypo-Osmolar Serum
Serum Osmolality
reduced <280 mosm/L
Normal P
OSM
Paraproteinemia
Hypertriglyceridemia
High P
OSM
> 295 mosm/L
Hyperglycemia
Mannitol
Impaired H
2
O Excretion
Intact H
2
O
Excretion Ability
Hypo-Osmolar Urine
Polydipsia
Low osmole intake
Impaired Desalination
Diuretics
Gitelman's/Bartter's
Syndromes
Hyper-Osmolar Urine
ADH functioning despite
Hypo-Osmolar state
Decreased Glomerular
Filtration Rate
GFR < 20mL/min
Acute Renal Failure
Syndrome of
Inappropriate ADH
Normal Effective Arterial Blood Volume
Malignant Tumors
Pulmonary Disease
Neuropsychiatric Disease
Severe Pain & Nausea
Drugs
Decreased Effective
With Edema
Cirrhosis
True Hypovolemia
Renal Loss
Gastrointestinal Tract Loss
Hormonal Changes
Hypothyroidism
Pregnancy
103
HYPERNATREMIA
Hypernatremia
Serum Sodium > 145 mmol/L
Net Water Deficit
Most common, no symptoms of
ECF volume expansion
Salt Excess
Rare cause, ECF volume expansion
Exogenous
Hypertonic Saline/Sodium
Bicarbonate
Administration
Excess Water Loss
Inadequate H
2
O Intake
Reduced urine volume and
concentrated urine
Decreased Thirst
(Decreased Level of
Consciousness)
Reduced access to water
Endogenous
Primary Aldosteronism
Renal Loss
Increased urine volume
Diabetes Insipidus
Osmotic Diuresis
Gastrointestinal
Tract Loss
Reduced urine volume and
concentrated urine
Watery Diarrhea
Insensible Loss
Burns
Inadequate hydration for
extreme exercise (e.g.
marathon runners)
ICU Patients
Fever See Polyuria Scheme
104
HYPOKALEMIA
*TTKG = (K
Urine
x Osm
Serum
)/(K
Serum
x Osm
Urine
)
Decreased Intake
Rare cause in isolation
Increased Loss
Intracellular Shift
No evidence of increased loss
Insulin
Beta-2 Stimulation
Alkalemia
Refeeding Syndrome
Rapid increase in cell
proliferation (e.g. Leukemia,
correction of Anemia)
Hypokalemia
Serum Potassium <3.5 mmol/L
Gastrointestinal Loss
Urine Loss <20 mmol/day
Urine Loss
Urine Loss >20 mmol/day
Upper Gastrointestinal
Vomiting
Nasogastric Drainage
Lower Gastrointestinal
Diarrhea
Laxative
TTKG > 4
High Cortical Collecting Duct [K
+
]
TTKG < 4
High Cortical Collecting Duct Flow
(See Polyuria scheme)
Osmotic Diuretics
Post-Obstructive Diuresis
Effective Arterial Blood
Volume Normal/Increased
Effective Arterial Blood
Volume Contracted
Loop Diuretics/Bartter's
Syndrome
Thiazide Diuretics/Gitelman's
Syndrome
Magnesium Depletion
High Renin
High Aldosterone
Reninoma
Low Renin
High Aldosterone
Primary or Secondary
Hyperaldosteronism
Glucocorticoid Remediable
Aldosteronism
Low Renin
Low Aldosterone
Non-Aldomineralcorticoid
Excess (Licorice)
Congenital Adrenal
Hyperplasia
105
HYPERKALEMIA: Intracellular Shift
*TTKG = (K
Urine
x Osm
Serum
)/(K
Serum
x Osm
Urine
)
Hyperkalemia
Serum Potassium > 5.5 mmol/L
Rule Out Pseudohyperkalemia (Leukocytosis,
Thrombocytosis, Hemolysis, Fist Clenching)
Intracellular Shift
Appropriate renal excretion (GFR,
TTKG*, distal flow adequate)
Increased Intake
IV Potassium (plus reduced
excretion)
Reduced Excretion
Increased Release
Increased Serum Osmoles,
Increased Urate, Phosphate,
Creatine Kinase
Non-Anion Gap Metabolic
Acidosis
Hyperosmolarity
Cell Lysis (e.g. Tumor Lysis
Syndrome, Rhabdomyolysis)
Decreased Entry
Decreased Na
+
-H
+
Exchanger
Decreased Na
+
-K
+
-ATPase
Insulin Deficiency/Resistance
Beta-2 Blockade
Alpha-1 Stimulation
Digoxin
106
HYPERKALEMIA: Reduced Excretion
Hyperkalemia
Serum Potassium > 5.5 mmol/L
Rule Out Pseudohyperkalemia (Leukocytosis,
Thrombocytosis, Hemolysis, Fist Clenching)
Intracellular Shift
Appropriate renal excretion (GFR,
TTKG*, distal flow adequate)
Increased Intake
excretion)
Reduced Excretion
Decreased Glomerular
Filtration Rate (<20)
excretion)
Principal Cell
TTKG* < 7
Reduced Distal Flow
Urine Sodium low (< 20 mmol/day) /
Hypotension
High Renin
High Aldosterone
Spironolactone
K
+
Sparing Diuretics
Acute Interstitial Nephritis
Chronic Interstitial Nephritis
Obstruction
High Renin
Low Aldosterone
ACE Inhibitors/Angiotensin
Receptor Blockers
Heparin
Low Renin
Low Aldosterone
Diabetic Nephropathy
Beta-1 Blockade
Non-steroidal Anti-
Inflammatory Drugs
*TTKG = (K
Urine
x Osm
Serum
)/(K
Serum
x Osm
Urine
)
107
SUSPECTED ACID-BASE DISORDER
Suspected Acid-Base Disorder
*Diagnosis of Mixed Metabolic Disorders in Patients with Metabolic Acidosis:
Anion Gap Not Increased: Non-Anion Gap Acidosis Alone
Anion Gap = HCO
3
-
: Anion Gap Acidosis Alone
Anion Gap < HCO
3
-
: Mixed Anion Gap Acidosis + Non-Anion Gap Acidosis
Anion Gap > HCO
3
-
: Mixed Anion Gap Acidosis + Metabolic Alkalosis
Acidemia
pH < 7.35
Normal pH
pH 7.35 7.45
Normal Arterial Blood Gas
Mixed Acid-Base Disorder*
Alkalemia
pH > 7.45
Respiratory Alkalosis
pCO2 < 35 mmHg
Metabolic Acidosis
HCO3
-
< 24 mmol/L
HCO3
-
: CO2 10:12
Respiratory Acidosis
pCO2 > 40 mmHg
Metabolic Alkalosis
HCO3
-
> 28 mmol/L
HCO3
-
: CO2 10:7
Acute
HCO3
-
: CO2 2:10
Non-Anion Gap
Renal
Gastrointestinal
Acute
HCO3
-
: CO2 1:10
Chronic
HCO3
-
: CO2 3:10
Anion Gap
Acetylsalicylic
Acid
Methanol
Uremia
Diabetic
Ketoacidosis
Propylene Glycol
Isoniazid
Lactic Acidosis
Ethylene Glycol
Chronic
HCO3
-
: CO2 4:10
108
METABOLIC ACIDOSIS: Elevated Anion Gap
Metabolic Acidosis
Need to correct anion gap for albumin
For every drop of 10 for albumin (from 40) add 2.5 to the anion gap
Elevated Anion Gap (> 14)
Acid Gain
Normal Anion Gap ( 14)
Loss of Bicarbonate
Decreased Ammonium
Production and Anion Excretion
Elevated Serum Creatinine
Acute Renal Failure
Excess Acid Addition
Normal Serum Creatinine
Metabolism/Endogenous
Elevated Plasma Ketones or Lactate
Ketoacidosis
Lactic Acidosis
Exogenous
Non-Alkaline Urine or Low Urine Sodium
Methanol/Ethanol
Ethylene Glycol
Salicylates
109
METABOLIC ACIDOSIS: Normal Anion Gap
Metabolic Acidosis
Need to correct anion gap for albumin
For every drop of 10 for albumin (from 40) add 2.5 to the anion gap
Acid Gain
Normal Anion Gap ( 14)
Loss of Bicarbonate
Extrarenal Loss
Negative Urine net charge
Preserved Ammonium production
Renal Loss
Diarrhea
Fistula
Direct Loss
Negative Urine net charge
High Fractional Excretion of Bicarbonate
Preserved Ammonium production
Renal Tubular Acidosis Type II
Carbonic Anhydrase Inhibitor
Indirect Loss
Positive Urine net charge
Reduced Ammonium production
Interstitial Nephritis/Obstruction
High TTKG*
Renal Tubular Acidosis Type IV
(Principal Cell Problem)
Low TTKG*
Renal Tubular Acidosis Type I (-
Intercalated Cell Problem)
*TTKG = (K
+
Urine
x Osm
Serum
)/(K
+
Serum
x Osm
Urine
)
110
METABOLIC ALKALOSIS: Contracted EABV
Metabolic Alkalosis
Expanded Effective
No signs of volume depletion
Signs of volume depletion
Renal Failure with
Ingestion
Decreased GFR and
receiving Bicarbonate
Milk Alkali Syndrome
Bicarbonate Ingestion
Transient
Intravenous Bicarbonate
Corrected Hypercapnia
Gastrointestinal Loss
Low Urine Chloride
Renal Loss
Gastric
Alkaline Urine with
inappropriately high Urine Sodium
Vomiting
Nasogastric Drainage
Lower Bowel
Non-Alkaline Urine with
low Urine Sodium
Villous Adenoma
Laxative Abuse
Chloridorrhea
Non-Reabsorbed Anions
Unmeasured anion in urine
(Positive Urine net charge)
Penicillin
Ampicillin
Carbenicillin
Impaired Tubular
Transport
Urine positive for Diuretic/Low Serum
Mg/Hypercalciuria/Hypomagnesuria
Diuretics
Inherited Tubular Disorder
Hypomagnesemia
111
METABOLIC ALKALOSIS: Expanded EABV
Metabolic Alkalosis
Expanded Effective
No signs of volume depletion
Signs of volume depletion
Renal Failure with
Ingestion
Decreased GFR and
receiving Bicarbonate
Milk Alkali Syndrome
Bicarbonate Ingestion
Transient
Intravenous Bicarbonate
Corrected Hypercapnia
High Renin
High Aldosterone
Malignant Hypertension
Renovascular Hypertension
Renin-Secreting Tumor
Low Renin
High Aldosterone
Adenoma
Carcinoma
Hyperplasia
Glucocorticoid Remediable
Aldosteronism
Low Renin
Low Aldosterone
Licorice
Enzyme Deficiency
Liddle's Syndrome
112
See Dysuria Scheme
Neurologic
Stimulants (e.g.
Caffeine, Alcohol)
Detrusor Hyperactivity
Inflammation/
Infection
Obstruction
Benign Prostatic
Hypertrophy (Enlarged
Prostate on Digital
Rectal Exam)
Anatomic
Small Volume Bladder
INCREASED URINARY FREQUENCY
Increased Urinary Frequency
Distinguish from polyuria by virtue of NON-INCREASED urine volume (<2mL/min)
Intrinsic to Urinary Tract Extrinsic to Urinary Tract
Vulvovaginitis
Bladder Compression
Pyuria No Blood/
Bacteria
Cystitis
Pyelonephritis
Pyuria With Blood/
Bacteria
Urethritis
Tender Prostate on
DRE +/- Abscess
Prostatitis
See Dysuria Scheme
113
POLYURIA
Polyuria
Osmotic Diuresis
Urine Osmolality > Serum Osmolality
> 1000 mOsm/day
Water Diuresis
Urine Osmolality < Serum Osmolality
< 800 mOsm/day
Urine Output > 3L/day
Increased Urine Volume (> 2mL/min) +
Lack of Other Urinary Abnormalities
Hyperglycemia (uncontrolled
Diabetes Mellitus)
Mannitol administration
Increased urea concentration (e.g.
Recovery from Acute Renal
Failure, increased protein feeds,
Hypercatabolism [Burns, Steroids],
GI Bleed, NaCl administration)
Hypotonic Urine Following
Water Deprivation Test
Excessive Loss
Hypertonic Urine Following
Water Deprivation Test
Excessive Water Intake
Following DDAVP
Hypotonic Urine
Uosm Unchanged
Following DDAVP
Hypertonic Urine
Uosm Increase by >50%
Hypothalamic Diabetes Insipidus Nephrogenic Diabetes Insipidus
114
Dysuria
DYSURIA
Pyuria
Positive for Leukocytes on
Dipstick/Microscopy
No Pyuria
No Leukocytes on
Dipstick/Microscopy
Non-Pathogenic
Estrogen Deficiency
Interstitial Cystitis
Vaginitis
Candida
Gardnerella
Carcinoma
Urethritis
Candida
Herpes Simplex
Virus
No Bacteriuria &
No Hematuria
Dipstick negative for nitrites.
No bacteria, no red cells
on microscopy.
Gonococcus
Non-Gonococcus (e.g.
Chlamydia,
Trichomonas)
Bacteriuria &
Hematuria
Dipstick positive for nitrites
(if infected with enterobacteria).
Bacteria and isomorphic red
blood cells on microscopy.
Upper Urinary Tract
Infection/
Pyelonephritis
WBC Casts
Lower Urinary Tract
Infection/Cystitis
No WBC Casts
115
NEPHROLITHIASIS
Nephrolithiasis
Calcium Containing Stones
Radioopaque: 90% of stones
Non-Calcium Stones
10% of stones
Uric Acid Stones
Radiolucent/
Uric acid calculi on microscopy/
History of gout
Hyperuricosuria
High protein intake
Hard Stones
80% of Stones
Calcium Oxalate on stone analysis,
occasionally Calcium Phosphate
Soft Stones
10% of Stones: Struvite
Staghorn Calculus
Pyelonephritis with Urea-
Splitting Microorganism
Struvite (MgNH
4
PO
4
) +/-
Calcium Carbonate
Apatite on stone analysis
Cystine Stones
Radioopaque (less calcium
containing)/Hexagonal cystine
crystals on microscopy/
Usually positive family history
Cystinuria
Anatomical Problem
Medullary Sponge Kidney
Stones with
Decreased Solubility
Low urine volume
Hypocitraturia
Renal Tubular Acidosis
Type I
High Protein Intake
Hypercalciuria
Increased Parathyroid
Hormone
Dietary (e.g. high salt
intake/high protein intake)
Hyperoxaluria
Enteric Overproduction
Dietary (e.g. low calcium
intake)
116
URINARY INCONTINENCE
Urinary Incontinence
Transient
New onset/Easily reversible cause
DIAPPERS
Delirium / confusional states
Infection (UTI)
Atrophic urethritis/vaginitis
Pharmaceuticals
Psychological/psychiatric
Excessive urine output
Restricted mobility
Stool impaction
Established
Not new onset/Not easily reversible cause
Stress Incontinence
Failure of urethral sphincter to remain
closed
Small volume
Precipitated by stress maneuvers
More common in multiparous women
Overflow Incontinence
Distended bladder with
increased residual volume
Continuous small volume leakage
+/- Precipitated by stress maneuvers
Urge Incontinence
Detrusor overactivity
Abrupt urgency
Moderate to large leakage of urine
Precipitated by cold temperature &
running water
Impaired Detrusor
Contraction
Signs of Autonomic Neuropathy or
Spinal Cord disease
Bladder Outlet Obstruction
117
Urinary Tract Obstruction
URINARY TRACT OBSTRUCTION
Bladder & Below
Bladder usually distended
Urgency, Frequency, Hesitancy, Nocturia,
Post-void dribbling, High post-void residual,
Decreased stream, Overflow Incontinence
Above Bladder
Bladder NOT usually distended
Flank pain, Nausea/Vomiting,
Hematuria, Pallor, Weakness
Outflow Tract
Prostatic changes on Digital
Rectal Exam,
Filling defect on IVP
Benign Prostatic
Hypertrophy
Prostate Cancer
Urethral Stricture
Urethral Carcinoma
Extraluminal
Retroperitoneal mass on CT
Retroperitoneal
Fibrosis
Cancer
Lymphoma
Intramural
Stricture on IVP or retrograde
cystoureterogram
Ureteropelvic
Junction Obstruction
Iatrogenic
Ureterovesical
Junction Obstruction
Tuberculosis
Bladder
Filling defect on IVP or U/S,
Radioopaque calculus
on X-ray, Cystoscopy with
bladder washings
Calculi
Carcinoma
Intraluminal
Intraluminal obstruction on IVP
Radioopaque calculus
on X-Ray
Calculi
Papillary Necrosis
Clot
Fungal Ball
In children also consider: Meatal Stenosis,
Posterior Urethral Valves, Ectopic Ureter, Ureterocele
118
RENAL MASS: Solid
Renal Mass
Solid Cystic
Benign
<3 cm in size
Features of Angiomyolipoma
(Fat density on CT, echogenic on U/S)
Angiomyolipoma
Oncocytoma
Von Hippel-Lindau Syndrome
Tuberous Sclerosis
Suspicious
>3 cm in size
No features of Angiomyolipoma
Carcinoma (assume Renal
Cell Carcinoma)
119
RENAL MASS: Cystic
Renal Mass
Solid Cystic
Benign
Anechoic on ultrasound
Well-demarcated on ultrasound/CT
Non-enhancing with CT contrast
Suspicious
Septated/Loculated on ultrasound
Irregular border on ultrasound/CT
Enhancing with CT contrast
Simple Cysts
No family history of ADPKD
Normal sized kidneys
No cysts in other organs
Carcinoma
No signs of infection (Assume Renal
Cell Carcinoma)
Abscess
Fever and leukocytosis
Positive Gallium scan
Polycystic
Multiple bilateral cysts
Positive family history
Enlarged kidneys
Cysts in other organs
Autosomal Dominant
Autosomal Recessive
Others (e.g. Tuberous
Sclerosis, Von Hippel-Lindau
Syndrome)
120
SCROTAL MASS
Does Not
Transilluminate
Sudden Onset
Testicular Torsion
Torsion of the Testicular
Appendix
Trauma
Incarcerated Hernia
Hemorrhage into
Testicular Tumor
Gradual Onset
If with Dysuria see Dysuria scheme
Epididymitis
Epididimo-orchitis
Transilluminates
Scrotal Mass
Painful Painless
Tumor
Solid = Tumor until proven
otherwise
Teratoma
Seminoma
Benign Tumor
Spermatic Cord
Hydrocele of Cord
Hydrocele
Separate from
Testes and Epididymis
Varicocele
Soft/Bag of Worms
Epididymal
Epididymal Cyst
Spermatocele
Communicating
Non-
Communicating
Simple
Reactive (Especially
if abrupt onset +/-
mass or tenderness)
121
Endocrinologic Presentations
Abnormal Serum TSH 123
Hyperthyroidism 124
Hypothyroidism 125
Adrenal Mass: Benign 126
Adrenal Mass: Malignant 127
Amenorrhea 128
Breast Discharge 129
Gynecomastia: Increased Estrogen &
Increased HCG 130
Gynecomastia: Increased LH &
Decreased Testosterone 131
Male Sexual Dysfunction 132
Hirsutism 133
Hirsutism & Virilization:
Androgen Excess 134
Hirsutism & Virilization: Hypertrichosis 135
Sellar/Pituitary Mass: Size 136
Sellar/Pituitary Mass 137
Short Stature 138
Tall Stature 139
Hypocalcemia: Low Phosphate 140
Hypocalcemia: High Phosphate 141
Hypercalcemia: Normal/High PTH 142
Hypercalcemia: Low PTH 143
Hypoglycemia 144
Hyperglycemia 145
Hypophosphatemia 146
Hyperphosphatemia 147
Abnormal Lipid Profile:
Combined & Decreased HDL 148
Abnormal Lipid Profile: Increased LDL &
Increased Triglycerides 149
Weight Gain/Obesity 150
122
Student Editors
Jonathan Dykeman (Section Editor)
Ataa Azarbar
Sudhakar Sivapalan
Jennifer Bjazevic
Arjun Rash
Michael Prystajecky
Faculty Editors
Dr. Hanan Bassyouni
Dr. David Hanley
Dr. David Stephure
123
ABNORMAL SERUM TSH
Abnormal Serum TSH
Decreased TSH Increased TSH
Decreased Free T4
Hypopituitarism
Normal Free T4 Increased Free T4
Thyrotoxicosis
Decreased Free T3
Non-Thyroid Illness
Increased Free T3
T3 Toxicosis
Normal Free T3
Sub-clinical
Thyrotoxicosis
Decreased Free T4
Hypothyroidism
Normal Free T4
Sub-clinical
Hypothyroidism
Recovery from Non-
Thyroid Illness
124
Hyperthyroidism
HYPERTHYROIDISM
High/Normal
Radioiodine Uptake
Low Radioiodine
Uptake
Autoimmune
Thyroid Disease
Grave's Disease
Positive anti-TSH
Antibody
Autonomous
Thyroid Tissue
Toxic Adenoma
Toxic Multinodular
Goiter
TSH/HCG Excess
TSH-Secreting
Pituitary Adenoma
Gestational
Trophoblastic
Neoplasm
Subacute
Thyroiditis
Granulomatous
Lymphocytic
Postpartum
Amiodarone
Radiation
Exogenous/Ectopic
Hormone
Excessive Thyroid
Drug
Struma Ovarii
125
Hypothyroidism
HYPOTHYROIDISM
Primary
Hypothyroidism
Thyroid Hormone
Resistance
Iatrogenic
Central
Hypothyroidism
Isolated TSH
Deficiency
Panhypopituitarism
Chronic
Infiltrative Disease
Fibrous Thyroiditis
Hemosiderosis
Congenital Thyroid
Agenesis/Degenesis
Severe Iodine
Deficiency
Medications
Thionamides
Lithium
Amiodarone
Interferon
Central
Hypothyroidism
Hashimoto's
Thyroiditis
Transient
Subacute
Lymphocytic/
Granulomatous
Thyroiditis
Post-Partum
Thyroiditis
Subtotal
Thyroidectomy
126
ADRENAL MASS: Benign
Benign Adrenal Mass
Most common neoplasm is Benign Non-Functioning Adenoma
Signs of Hormone Excess
No Signs of
Hormone Excess
Positive 24-
Hour
Metanephrines
+ Nor-
Metanephrines
Pheo-
chromocytoma
(Paroxysmal
Hypertension,
Headache,
Diaphoresis,
Palpitations,
Anxiety)
Estrogen
Excess
Feminization,
Early Puberty,
Heavy Menses
Estrogen
Releasing
Adenoma (High
Plasma E
2
+
Clinical Picture)
Glucocorticoid
Excess
Cushingoid Features
Glucocorticoid
Releasing
Adenoma
(Positive Dexa-
methasone
Suppression
Test)
Aldosterone
Excess
Hypertension +/-
Hypokalemia/Alkalosis
Aldosterone
Releasing
Adenoma (High
Aldosterone:
Renin Ratio)
Androgen
Excess
Virilization/Hirsutism
Silent/Non-
Functioning
Mass
High DHEAS Normal DHEAS
Androgen
Releasing
Adenoma
Other Source
(e.g. Polycystic
Ovarian
Syndrome,
Congenital
Adrenal
Hyperplasia)
Hyperplasia
Often Bilateral
Congenital
Adrenal
Hyperplasia
ACTH
Dependent
ACTH
Independent
Macronodular
Hyperplasia
Other
Cyst
Pseudocyst
Hematoma
Infection (TB,
Fungal)
Amyloidosis
Normal DHEAS
Non-functioning
Adenoma
Lipoma
Myelolipoma
Ganglioneuroma
Rule of 10's For
Pheochromocytoma:
10% are Malignant
10% are Bilateral
10% are Extra-Adrenal
10% are Familial
10% are not Associated
with Hypertension
127
ADRENAL MASS: Malignant
Malignant Adrenal Mass
Suggestive of Malignancy: Inhomogenous Density, Delay in CT Contrast Washout
(<50% in 10 minutes), Irregular Shape, Diameter >4 cm, Calcification, >20 Hounsfeld Units on CT,
Vascularity of Mass, Hypointense to Liver on T1 Weighted MRI - DO NOT Biopsy
Signs of Hormone Excess
No Signs of
Hormone Excess
Positive 24-Hour
Metanephrines +
Nor-
Metanephrines
Pheo-
chromocytoma
(Paroxysmal
Hypertension,
Headache,
Diaphoresis,
Palpitations,
Anxiety)
Estrogen Excess
Feminization,
Early Puberty,
Heavy Menses
Estrogen
Releasing
Carcinoma (High
Plasma E
2
+
Clinical Picture)
Glucocorticoid
Excess
Cushingoid Features
Glucocorticoid
Releasing
Carcinoma
(Positive
Dexamethasone
Suppression
Test)
Aldosterone
Excess
Hypertension +/-
Hypokalemia/Alkalosis
Aldosterone
Releasing
Carcinoma (High
Aldosterone:
Renin Ratio)
Androgen
Excess
Virilization/Hirsutism
Silent/Non-
Functioning
Mass
Lymphoma
Metastases
(Often Bilateral)
Adrenal
Carcinoma
High DHEAS Normal DHEAS
Androgen
Releasing
Carcinoma (e.g.
Adrenocortical
Carcinoma)
Other Source
(e.g. Polycystic
Ovarian
Syndrome,
Congenital
Adrenal
Hyperplasia)
Rule of 10's For
Pheochromocytoma:
10% are Malignant
10% are Bilateral
10% are Extra-Adrenal
10% are Familial
10% are not Associated
with Hypertension
128
Amenorrhea
AMENORRHEA
Rule Out Pregnancy
Low/Normal FSH Elevated FSH
Premature Ovarian
Failure
Menopause
Spontaneous
Hypothalamic-
Pituitary Axis
Bleed With
Progestin Challenge
Hypothyroidism
Hyperthyroidism
Diabetes Mellitus
Exogenous Androgen
Use
Congenital
Abnormalities
Bleed With
Progestin Challenge
Polycystic Ovarian
Syndrome
Failed Progestin
Challenge
Functional
Hypothalamic
Amenorrhea (e.g.
Weight Loss, Eating
Disorders, Exercise,
Stress, Prolonged
Illness)
Organic Cause
Congenital GnRH
Deficiency
Infiltrative or
Inflammatory Lesion
Tumors
Infarction
Empty Sella
Syndrome
Apoplexy
High Prolactin
Hyperprolactinemia
129
BREAST DISCHARGE
Breast Discharge
True Galactorrhea
(on microscopy)
Other Breast
Discharge
Abnormal TSH/
Prolactin
Normal TSH/
Prolactin
Neoplasm or Other
Internal Breast
Discharge
Idiopathic
High Prolactin +
Normal TSH
Microprolactinoma
Steroid Hormone Intake
Stress (e.g. Pregnancy,
Breast Stimulation,
Trauma/Surgery)
High Prolactin +
Normal/Low TSH
Pituitary Macroadenoma
Dopamine Inhibition
Pituitary Stalk
Compression/Lesion
Autonomous
Production
Renal Cancer or Failure
Lactotroph Adenoma
Bronchogenic Tumor
Contraceptive Pill/Patch/
Ring
High Prolactin +
High TSH
Primary Hypothyroidism
130
GYNECOMASTIA: Increased Estrogen & Increased HCG
Gynecomastia
True Gynecomastia
Pseudogynecomastia
Fat Deposition Only
Physiologic
Newborns
Pubescent Adolescent
Elderly
Increased LH
Decreased
Testosterone &
Normal/Low LH
Increased HCG
Increased
Estrogen
Normal Blood
Work
Idiopathic
No Testicular Mass
on Ultrasound
Adrenal Neoplasm
Increased
Extraglandular
Aromatase Activity
Testicular Mass on
Ultrasound
Leydig Cell Tumor
Sertoli Cell Tumor
No Testicular Mass
on Ultrasound
Extragonadal Germ
Cell Tumor
HCG Secreting Non-
Trophoblastic
Neoplasm
Testicular Mass on
Ultrasound
Testicular Germ Cell
Tumor
131
Normal Prolactin
Non-Tumor
Secondary
Hypogonadism
Testicular Germ Cell
Tumor
GYNECOMASTIA: Increased LH & Decreased Testosterone
Gynecomastia
True Gynecomastia
Pseudogynecomastia
Fat Deposition Only
Physiologic
Newborns
Pubescent Adolescent
Elderly
Increased LH
Decreased
Testosterone &
Normal/Low LH
Increased HCG
Increased
Estrogen
Normal Blood
Work
Decreased
Testosterone
Hypogonadism
Klinefelter's
Syndrome
Kallman's Syndrome
Testicular Torsion
Testicular Trauma
Congenital Anorchia
Viral Orchitis
Increased
Testosterone
Increased T4,
Decreased TSH
Hyperthyroidism
Normal T4 and
TSH
Androgen
Resistance
Increased
Prolactin
Prolactin Secreting
Tumor
132
Physiological
MALE SEXUAL DYSFUNCTION
Sexual Dysfunction
Erectile Dysfunction
Desire
Reduced/Absent
Chronic Disease
Diabetes
Cardiovascular
Disease
Peyronie's
Connective Tissue
Disease
Neurological
Stroke
Spinal Cord Injury
Multiple Sclerosis
Dementia
Polyneuropathy
Physiological
Hypo-
testosteronism
Prolactinemia
Hypothyroidism
Hyperthyroidism
Pelvis
Trauma
Pelvic Surgery
Prostate Surgery
Priapism
Infection
Bicycling
Other
Hypertension
Dyspareunia
Dialysis
Establish Dysfunction in Context - Partner Showing Less Desire is not Necessarily Impaired
Global Dysfunction Most Likely Organic Cause
Situational Impairment Most Likely Psychological
Psychological
Mood Disorders
Anxiety Disorders
Guilt
Stress
Interpersonal
Issues (e.g. Lack
of trust in partner)
Psychosis/
Delusions
Previous psycho-
social trauma
(e.g. Abuse)
Pharmacological
Anti-depressants
Narcotics
Anti-psychotics
Anti-androgens
Alcohol
Benzodiazepines
Hallucinogens
Physiological
Hypo-
testosteronism
Prolactinemia
Hyper-
estrogenism
Hypothyroidism
Hyperthyroidism
Chronic Pain
Psychological
Performance
Anxiety
Lack of Sensate
Focus
Mood Disorder
Anxiety Disorder
Stress
Guilt
Interpersonal
Issues
Pharmacological
Anti-
hypertensives
Anti-depressants
Diuretics
Benzodiazepines
Alcohol
Sympathomi-
metic Drugs (e.g.
Cocaine,
Amphetamines)
133
Hirsutism
HIRSUTISM
Rule Out Virilization
Rapid Onset Slow Onset
Medications
Steroids
Danazol
Progestin
Containing
Contraceptives
Increased Serum
Testosterone
Ovarian Neoplasm
Hypertrichosis
Increased Serum
DHEAS
Adrenal Neoplasm
Regular
Menstrual Cycles
Familial
Idiopathic
Ethnic Background
Irregular
Menstrual Cycles
Polycystic Ovarian
Syndrome
Cushing's
Syndrome
21-OH Congenital
Adrenal
Hyperplasia
134
Hirsutism & Virilization
HIRSUTISM & VIRILIZATION: Androgen Excess
Androgen Excess
Normally With Menstrual Irregularity
Hypertrichosis
Non-Androgen Distribution
Ovarian
Polycystic Ovarian
Syndrome
Hyperthecosis
Tumor
Adrenal
Congenital Adrenal
Hyperplasia
Cushing's Syndrome
Tumor
Low Serum
Hormone Binding
Globulin
Obesity
Liver Disease
Insulin Resistance
Syndrome
Medications
Testosterone
DHEA
Danazol
Idiopathic
Hirsutism
Normal Cycles and
Androgen Levels
135
HIRSUTISM & VIRILIZATION: Hypertrichosis
Hirsutism & Virilization
Androgen Excess
Normally With Menstrual Irregularity
Hypertrichosis
Non-Androgen Distribution
Medical/Other
Hypothyroidism
Anorexia Nervosa
Malnutrition
Porphyria
Dermatomyositis
Paraneoplastic
Syndrome
Familial
Idiopathic
Medications
Phenytoin
Cyclosporine
Minoxidil
Penicillamine
Diazoxide
136
Sellar/Pituitary Mass
SELLAR/PITUITARY MASS: Size
Small
(<1 cm)
Hypersecretion
Large
(>1 cm)
Hypersecretion
Hyposecretion
Other
137
Sellar/Pituitary Mass
SELLAR/PITUITARY MASS
Adenoma
Primarily Anterior Pituitary
Hyperplasia
Physiological (e.g.
Pregnancy)
Compensation (e.g.
Hypothyroidism)
Stimulatory (e.g. Ectopic,
GHRH, CRH)
Inflammatory
Infectious
Autoimmune
Giant Cell Granuloma
Langerhan's Cell
Histiocytosis
Sarcoidosis
Non-Adenomatous
Secreting
Prolactin
GH
ACTH
TSH
LH/FSH
Mixed
Non-
Functioning
Oncocytoma
Null Cell
Adenoma
Vascular
Aneurysm
Infarction
Hamartoma Neoplasm
Cranio-
pharyngioma
Meningioma
Cyst
Glioma
Ependymoma
Metastatic
138
SHORT STATURE
Short Stature
< 3
th
Percentile
Detailed History, Physical Exam, and Mid-parental Target Height
Pathological/Abnormal Normal Variant
Proportionate
No Dysmorphic
Features
Dysmorphic Features
Trisomy 21
Noonan Syndrome
Prader-Willi Syndrome
Russell-Silver
Syndrome
Turner Syndrome
Deprivation
Primary Malnutrition
Psychosocial
Deprivation
Endocrine
Cushing's Disease
GH Deficiency
IGF-1 Deficiency (e.g.
Laron Dwarfism)
Hypothyroidism
Congenital Adrenal
Hyperplasia
Panhypopituitarism
Treatment
Glucocorticoids
Radiation
Chemotherapy
Bone Marrow
Transplant
Chronic Disease
GI (e.g. Celiac, IBD)
Renal (e.g. CRF)
Infection (e.g. Chronic
UTI)
Cardiopulmonary (e.g.
Cystic Fibrosis, CHF)
Inborn Metabolism
Error
Immunologic
Hematologic
Intrauterine Growth
Retardation
Bulimia Nervosa
Anorexia Nervosa
CNS Tumors (e.g.
Craniopharyngioma)
Other
Normal Puberty
Onset (BA=CA)
Familial Short Stature
Delayed Puberty
Onset (BA<CA)
Constitutional Short
Stature (Late Bloomer)
Disproportionate
Skeletal Dysplasias
(e.g. Achondroplasia)
Rickets
139
TALL STATURE
Tall Stature
> 97
th
Percentile
Detailed History, Physical Exam, and Mid-parental Target Height
Other Obvious
Abnormalities/Stigmata
No Other Obvious
Abnormalities/Stigmata
Proportionate
Beckwith-Weidmann
Syndrome (Normalizing
growth after birth)
Weaver Syndrome
XYY Syndrome
Neurofibromatosis 1
Hyperthyroidism
(Untreated/Severe)
Normal Growth
(BA=CA)
Familial Tall Stature
XYY Syndrome
Accelerated Growth
(BA>CA)
Disproportionate
Klinefelter's Syndrome
(XXY)
Sotos Syndrome/
Cerebral Gigantism
Marfan's Syndrome
Homocystinuria
Sex Steroid Deficiency/
Resistance
Acromegaly (Rare in
Children)
Obese BMI Non-Obese BMI
Early Puberty Onset
Normal Puberty
Onset
Constitutional
Exogenous Obesity
GH Excess
Hyperthyroidism
Constitutional Tall
Stature (Early Bloomer)
Precocious Puberty
Adrenal Tumor
Ovarian Tumor
Testotoxicosis
Congenital Adrenal
Hyperplasia
140
HYPOCALCEMIA: Low Phosphate
Corrected total serum calcium concentration (mmol/L) =
measured total serum calcium concentration (mmol/L) + 0.02[40 g/L albumin(g/L)]
Hypocalcemia
Total Corrected Serum Calcium < 2.10 mmol/l
Low Phosphate High Phosphate
Low/Normal PTH
Severe Malnutrition with
Hypomagnesemia
High PTH
Vitamin D Deficiency (e.g.
Diet, Malabsorption,
Phenytoin, Nephrotic
Syndrome, Hepatobiliary
Disease)
Hereditary Vitamin D
Resistance
1--Hydroxylase
Deficiency
141
Hypocalcemia
Total Corrected Serum Calcium < 2.10 mmol/l
Low Phosphate
HYPOCALCEMIA: High Phosphate
High Phosphate
High Creatinine Normal Creatinine
Low/Normal PTH
Hypoparathyroidism (e.g.
Acquired, Autoimmune,
Idiopathic, Congenital,
infiltrative)
Activating Mutation in
Calcium Sensing
Receptor (CaSR)
Hypomagnesemia
High PTH
PTH Resistance (Pseudo-
hypoparathyroidism)
Calcium Complexing
(Citrate Infusion,
Pancreatitis)
Low PTH
Hypoparathyroidism with
High PTH
Secondary
Hyperparathyroidism
Rhabdomyolysis
Phosphate Poisoning
142
Hypercalcemia
Total Calcium > 2.55 mmol/L; Ionized Calcium > 1.30 mmol/L
HYPERCALCEMIA: Normal/High PTH
Normal/High PTH Low PTH
Measure In Fasting State
Drug Side Effects
Thiazide Diuretics
Lithium
Vitamin A/Isotretinoin
Tertiary
Hyperparathyroidism
Hypercalcemia (in the
setting of long-standing
secondary
hyperparathyroidism
(e.g. Renal Failure, Post-
Renal Transplant))
Familial Hypocalciuria
Hypercalcemia
Autosomal Dominant
Calcium Receptor
Mutation (CaSR)
Other Familial
Hypercalcemias (e.g.
MEN)
Primary
Hyperparathyroidism
Adenoma
Hyperplasia
MEN 1 and 2A
143
HYPERCALCEMIA: Low PTH
Hypercalcemia
Total Calcium > 2.55 mmol/L; Ionized Calcium > 1.30 mmol/L
Normal/High PTH Low PTH
Measure In Fasting State
Drug Side Effects
Thiazide Diuretics
Lithium
Vitamin A/Isotretinoin
Other
Excess Calcium Intake
(e.g. Milk Alkali)
Immobilization
Thyrotoxicosis
Vitamin D Related
Excess Vitamin D/
Calcitriol intake
Unregulated Conversion
of 25-OH D3 to 1,25-
(OH)2D3 (e.g.
Granulomatous Disease,
Lymphoma)
Malignancy
PTH-Related Peptide
(e.g. Breast, Kidney,
Lung)
Cytokine-Mediated Bone
Resorption (e.g. Multiple
Myeloma, Lymphomas)
Metastatic Bone Disease
144
HYPOGLYCEMIA
Signs/Symptoms of Hypoglycemia:
Neurogenic: irritability, tremor, anxiety, palpitations, tachycardia, sweating, pallor, paresthesias
Neuroglycopenic: confusion, lethargy, abnormal behaviour, amnesia, weakness, blurred vision, seizures
Hypoglycemia
(< 4 mmol/L)
Fasting Hypoglycemia
Excess Insulin
Medications (e.g. Insulin
Secretagogues, -Adrenergic
Antagonists, Quinine, Salicylates,
Pentamidine)
Alcohol
Post-Prandial
(Reactive)
Alimentary (e.g. in the setting of
Gastric Surgery)
Congenital Enzyme Deficiencies
Idiopathic
Other Causes
Critical Illness (e.g. Hepatic Failure,
Renal Failure, Cardiac Failure)
Sepsis
Hypopituitarism
Hyperinsulinemic States (e.g.
Glucagon, Catecholamine
Deficiency, Insulinoma)
Malnutrition/Anorexia Nervosa
145
Hyperglycemia
(> 6 mmol/L)
HYPERGLYCEMIA
Signs/Symptoms of Hyperglycemia:
Polyphagia, polydipsia, polyuria, blurred vision, fatigue and weight loss
Diabetes Mellitus
Impaired Glucose
Tolerance
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes
Endocrinopathy
Cushing's Syndrome
Acromegaly
Medications
Corticosteroids
Thiazide diuretics
agonists
Others
Critical Illness/
Physiologic Stress
Stress Hyperglycemia (e.g.
Trauma, Surgery, Burns,
Sepsis)
Shock
Acute Pancreatitis
Post-Stroke
Post-Myocardial Infarction
146
Hypophosphatemia
(< 0.8 mmol/L)
HYPOPHOSPHATEMIA
Transcellular Shift
Recovery From DKA
Refeeding Syndrome
Acute Respiratory Alkalosis
Hypokalemia
Hypomagnesemia
Burns
Increased Excretion
Hyperparathyroidism
Vitamin D Deficiency/Resistance
Hypophosphatemic Rickets
Oncogenic Osteomalacia
Fanconi Syndrome
Osmotic Diuresis
Acute Volume Expansion
Acetazolamide and Thiazide
Diuretics
Decreased Intake/Absorption
Aluminum/Magnesium
Containing Antacids
Inflammatory Bowel Disease
Steatorrhea
Chronic Diarrhea
Anorexia
Chronic Alcoholism
147
Hyperphosphatemia
(> 1.46 mmol/L)
HYPERPHOSPHATEMIA
Transcellular Shift
Rhabdomyolysis
Tumor Lysis
Metabolic or Respiratory
Acidosis
Insulin Deficiency
Decreased Excretion
Renal Disease
Hypoparathyroidism
Pseudo-hypoparathyroidism
Acromegaly
Bisphosphonate Therapy
Increased Intake/
Absorption
Normally in Context of
Impaired Renal Function
Hypervitaminosis D
Phosphate Supplementation
Phosphate Containing
Enemas/Laxatives
Pseudo-
hyperphosphatemia
Multiple Myeloma
Hyperbilirubinemia
Hemolysis
Hyperlipidemia
Tumor Lysis
148
ABNORMAL LIPID PROFILE: Combined & Decreased HDL
Abnormal Serum Lipid Profile
Increased LDL
Increased
Triglycerides
Increased Cholesterol
and Triglycerides
Decreased HDL
Genetic Causes
Familial Combined
Hyperlipidemia
Familial
Dysbetalipoproteinemia
Secondary Causes
Nephrotic Syndrome
Drugs
Diabetes
Genetic Causes
ApoA-1 Deficiency/
Variant
Tangier Disease
LCAT Deficiency
Primary Hypo-
alphalipoproteinemia
Secondary Causes
Sedentary Lifestyle
Smoking
Androgens
149
ABNORMAL LIPID PROFILE: Increased LDL &
Increased Triglycerides
Abnormal Serum Lipid Profile
Increased LDL
Increased
Triglycerides
Increased Cholesterol
and Triglycerides
Decreased HDL
Genetic Causes
Polygenic
Hypercholesterolemia
Familial
Hypercholesterolemia
Familial Defective
ApoB-100
Secondary Causes
Hypothyroid
Obstructive Liver
Disease
Nephrotic Syndrome
Genetic Causes
Familial
Hypertriglyceridemia
Familial LPL Deficiency
Apo-CII Deficiency
Secondary Causes
Diabetes
Alcohol
Increased Estrogen
(e.g. Pregnancy,
Hormone Replacement
Therapy, Oral
Contraceptive)
150
WEIGHT GAIN/OBESITY
Weight Gain/Obesity
Energy Related
(Primary)
Secondary
Genetic
Autosomal Dominant
Autosomal Recessive
X-Linked
Chromosomal
Abnormality
Neuroendocrine
Polycystic Ovarian
Syndrome
Hypothyroid
Cushing's Syndrome
Hypogonadism
GH Deficiency
Hypothalamic Obesity
Decreased
Expenditure
Sedentary Lifestyle
Smoking Cessation
Increased Intake
Dietary
Progressive
Polyphagia
High-Fat Diet
Social/Behavioural
Socioeconomic
Ethnicity
Psychological
Iatrogenic
Drugs/Hormones
Tube Feeding
Hypothalamic Surgery
151
Neurologic Presentations
Approach 153
GCS 7 154
Cognitive Impairment 155
Hemiplegia 156
Gait Disturbance 157
Falls in the Elderly 158
Movement Disorder: Hyperkinetic 159
Movement Disorder: Tremor 160
Movement Disorder: Bradykinetic 161
Vertigo/Dizziness: True Vertigo 162
Vertigo/Dizziness: Dizziness 163
Syncope 164
Spell/Seizure: Epileptic Seizure 165
Spell/Seizure: Secondary Organic 166
Spell/Seizure: Other 167
Mechanisms of Pain 168
Headache: Primary 169
with Red Flag Symptoms 170
without Red Flag Symptoms 171
Back Pain 172
Dysarthria 173
Aphasia: Fluent 174
Aphasia: Non-Fluent 175
Peripheral Weakness 176
Peripheral Weakness:
Sensory Changes 177
Stroke: Intracerebral Hemorrhage 178
Stroke: Subarachnoid Hemorrhage 179
Stroke: Ischemia 180
152
Unintentional Weight
Loss in the Elderly 181
Student Editors
John Booth (Section Editor)
Kaitlin Chivers-Wilson
Jeff Shrum
Khaled Ahmed
Nichelle Desilets
Sandeep Saran
Jonathan Dykeman
Anastasia Aristarkhova
Stephanie Yang
Vikram Lekhi
Lindsay Connolly
Siddhartha Srivastava
Faculty Editors
Dr. Kevin Busche
Dr. Darren Burback
Dr. Brian Klassen
Dr. Dawn Pearson
Dr. Oksana Suchowersky
Dr. Gary Klein
153
ALTERED LEVEL OF CONSCIOUSNESS: Approach
Altered Level of Consciousness
Clinical Exam
Glasgow Coma Scale Score:
12-15 = Investigate
8-12 = Urgent Investigation
> 7 = Resuscitate + Investigate
Rapidly Deteriorating = Resuscitate + Investigate
Blood Work Imaging
Metabolic
Abnormality
Hypoxia
Hypercapnea
Hyper/Hyponatremia
Hyper/Hypocalcemia
Hyper/Hypokalemia
Sepsis
Non-Focal
Refer to
Blood Work
and Imaging
Sections
No Metabolic
Abnormality
Post-Ictal
Concussion
Meningitis
Encephalitis
Structural
Abnormality
Epidural
Hemorrhage
Subdural
Hemorrhage
Intracranial
Hemorrhage
Ischemia
Tumor
Non-
Structural
Post-Ictal
Concussion
Encephalitis
Focal
Trauma
Stroke
Tumor
Hemorrhage
See Imaging
Section
154
ALTERED LEVEL OF CONSCIOUSNESS: GCS 5 7
GCS 5 7
Coma Other
Locked-in
Syndrome
Stupor
Persistent
Vegetative State
Brain
Involvement
Systemic
Involvement
Focal Lesions Diffuse Lesions
Hemispheric
Hemorrhage
Traumatic
Ischemia/
Infarction
Neoplastic
Abscess
Skull
Fracture
Subdural
Hematoma
Intracranial
Bleed
NB Must Be
Direct or
Indirect Bi-
Hemispheric
Involvement
Brain Stem
Hemorrhage
Traumatic
Ischemia/
Infarction
Neoplastic
Abscess
Herniation
Brain Stem
Lesion
Vascular
Hypertensive
Encephalopathy
Vasculitis
Thrombotic
Thrombocytopenic
Purpura
Diffuse
Intravascular
Coagulation
Hypoxemia
Multiple Emboli
Other
Trauma/
Concussion
Postictal
Infection
Meningitis
Encephalitis
Excesses
Liver/Renal Failure
Carbon Dioxide
Narcosis
Metabolic Acidosis
Hypernatremia
Hypercalcemia
Hypermagnesemia
Hyperthermia
Thyroid Storm
Deficiencies
Hypoxemia
Hypoglycemia
B12/Thiamine
Deficiency
Hyponatremia
Hypocalcemia
Hypomagnesemia
Hypothermia
Myxedema Coma
Drugs/Toxins
Alcohols
Barbiturates/
Tranquilizers
Other
155
COGNITIVE IMPAIRMENT
Cognitive Impairment
Affecting Multiple Domains
Depression
Delirium
Decline in Instrumental
Activities of Daily Living
Amnestic Mild Cognitive
Impairment
Non-Amnestic Mild Cognitive
Impairment
Dementia
Subcortical Dementia Cortical Dementia
Treatable Cause
Normal Pressure
Hydrocephalus
Chronic Meningitis
Chronic Drug Abuse
Tumor
Subdural Hematoma
B12 Deficiency
Hypothyroidism
Hypoglycemia
Early Extrapyramidal
Features
Parkinson's Disease with
Dementia
Huntington's Disease
Rapidly Progressive
Creutzfeldt-Jakob
Disease
Paraneoplastic Disorder
Early
Extrapyramidal
Features
Dementia with Lewy
Bodies
Early Impairment
of Recent Memory
Alzheimer's Disease
Abrupt Onset
Vascular Dementia
Early Language
and Behavioural
Dysfunction
Frontotemporal
Dementia
156
HEMIPLEGIA
Upper Motor Neuron Weakness
Cerebral Hemisphere
(Contralateral motor cortex)
Aphasia
Apraxia
Agnosia
Agraphia
Acalculia
Alexia
Anomia
Anosognosia
Asterognosia
Seizures
Personality Changes
Cognition/Confusion/
Dementia
+/- Sensory Loss
Contralateral/Subcortical
(Corona radiata/
Internal capsule)
May be without sensory loss
May be combined with
contralateral sensory loss
Brain Stem
Diplopia
Dysarthria
Dysphagia
Ptosis
Decreased Level of
Consciousness
Cranial Nerve Palsies
'Crossed' Sensory Findings:
Ipsilateral facial and
contralateral extremity
findings)
Unilateral Spinal Cord
Lesions Above ~C5
Brown-Sequard Syndrome
(Sensory loss to pain and
temperature contralateral to
weakness, vibration and
proprioception loss
ipsilateral to weakness)
Tone: Spastic with clasp-knife resistance
Reflexes: Hyperactive +/- Clonus
Pathological Reflexes: Babinski/Hoffman
157
GAIT DISTURBANCE
Sporadic
Vascular
Infection
Toxic
Nutrition
Metabolic
Inflammation
Neoplasm
Degenerative
Hereditary
Cerebellar Ataxia Sensory Ataxia
Vestibular
Visual
Proprioceptive
Progressive/
Degenerative
Gait Disturbance
Catalytic Deficiency
(Childhood)
Intermittent
Hyperammonemia
Aminoaciduria
Pyruvate/Lactic
Acid
Chronic
Progressive
Tay-Sachs
Disease
Niemann-Pick
Disease
Recessive
Friedrich's Ataxia
Telangiectasia
Dominant
Spinocerebellar
Ataxia
X-Linked/
Mitochondrial
Fragile X
Movement Disorder
See Movement Disorder
schemes
158
FALLS IN THE ELDERLY
Fall
Intrinsic Factors Extrinsic Factors
Cardiac
Non-Cardiac
Presyncope/
Syncope
Vision
Vestibular
Neuropathy
Sensory
Impairments
Weakness
Decreased
Balance
Gait
Abnormalities
Performance
Measures
Arthritis
Musculoskeletal
Stroke
Parkinsonism
Cognition
Depression
Other
Neurological/
Psychiatric
Greater than 4
Medications
Psychotropics
Drugs
Rugs
Stairs
Lighting
Environment
Normally is a combination of multiple factors
159
MOVEMENT DISORDER: Hyperkinetic
Movement Disorder
Bradykinetic Tremor
Tics
Tourette's
Syndrome
Attention
Deficit
Hyperactivity
Disorder
Obsessive
Compulsive
Disorder
Dystonia
Generalized
Dystonia
Writer's Cramp
Blepharospasm
Cervical
Dystonia
Stereotypies Myoclonus
Epilepsy
Toxic
Metabolic
Chorea
Huntington's
Disease
Athetosis Ballism
Hyperkinetic
Examples listed are not exhaustive
for all causes
160
MOVEMENT DISORDER: Tremor
Movement Disorder
Hyperkinetic Bradykinetic Tremor
Occurs During Voluntary
Muscle Movement
Cerebellar Diseas (eg.
Spinocerebellar Ataxi, Vitamin E
Deficienc, Stroke, Multiple
Sclerosis)
Occurs at Rest
Parkinson's Disease
Midbrain Tremor
Wilson's Disease
Progressive Supranuclear Palsy
Multiple System Atrophy
Drug-Induced Parkinsonism
Occurs While Held
Motionless Against Gravity
('PosturaI')
Enhanced Physiologic Change
Essential Tremor
Dystonia
Metabolic Etiology (Thyroid,
Liver, Kidney)
Drugs (Lithium Carbonate,
Amiodarone, Valproate)
161
MOVEMENT DISORDER: Bradykinetic
Movement Disorder
Hyperkinetic Bradykinetic Tremor
Parkinson's Disease
(TRAP)
Clinical Diagnosis:
Resting Tremor
Cogwheel Rigidity
Akinesia/Bradykinesia
Postural Instability
Drug-Induced
Parkinsonism
Neuroleptics
Haloperidol
Metoclopramide
Prochlorperazine
Amiodarone
Verapamil
Progressive
Supranuclear Palsy
Characteristics:
Vertical Gaze Palsy
Axial rigidity more
prominent than limb
rigidity
Tremor (possibly)
Bradykinesia
Falling backwards
Multiple System
Atrophy
Characteristics:
Bradykinesia
Tremor (possibly)
Cerebellar signs
Postural Hypotension
162
VERTIGO/DIZZINESS: True Vertigo
Vertigo/Dizziness
Dizziness
Lightheaded, unsteady,
disoriented
True Vertigo
Illusion of rotary movement
Central Vestibular
Dysfunction
Imbalance, neurologic symptoms/signs,
bidirectional nystagmus
Vascular
Vertebrobasilar
Insufficiency
Basilar Artery
Migraine
Transient
Ischemic Attack
Cerebellar/
Brainstem
Infarction
Cerebellar
Hemorrhage
Space-
Occupying
Lesion
Infratentorial
Tumors
Cerebellopontine
Angle Tumors
Glomus Tumors
Inflammatory
Multiple
Sclerosis
Infection
Meningitis
Cerebellar/
Brainstem
Abscess
Trauma
Cerebellar
Contusion
Peripheral Vestibular
Dysfunction
Nausea & vomiting, auditory
symptoms, unidirectional nystagmus
Benign Paroxysmal
Positional Vertigo
Labrynthitis/Vestibular
Neuronitis
Mnire's Disease
Acoustic Neuroma
Ototoxicity (Usually
Imbalance & Oscillopsia)
Otitis Media
Temporal Bone Fracture
Intoxication
Barbiturates
Ethanol
163
VERTIGO/DIZZINESS: Dizziness
Vertigo/Dizziness
Dizziness
Lightheaded, unsteady,
disorientated
True Vertigo
Illusion of rotary movement
Organic Disease
Presyncope/Vasodepressor
Syncope
Cardiac Arrhythmia
Orthostatic Hypotension
Hyperventilation
Anemia
Peripheral Neuropathy
Visual Impairment
Musculoskeletal Problem
Drugs
Psychiatric Disease
Depression
Anxiety
Panic Disorder
Phobic Dizziness
Somatization
164
SYNCOPE
Syncope
Non-Cardiac Cardiac
Arrhythmia
Tachyarrhythmia
Bradyarrhythmia
Supraventricular
Tachycardia
Sick-Sinus Syndrome
Second/Third Degree Atrio-
Ventricular Block
Vasovagal/Autonomic Orthostatic
Dehydration
Hypovolemia
Medications
Outflow Obstruction
Aortic Stenosis
Hypertrophic Obstructive
Cardiomyopathy
Pulmonary Embolus
Other
Central
Emotional
Peripheral/Situational
Bladder Emptying
Pain
Reduced Effective Arterial
Blood Volume
Carotid Sinus Syncope
Tussive
Defecation
165
SPELL/SEIZURE: Epileptic Seizure
Spell/Seizure
Unprovoked Recurrence
(Primary)
Epileptic seizure
Provoked Recurrence
(Secondary)
Non-epileptic organic
seizure/other
Generalized Unclassified Focal (Partial)
Complex
(Level of awareness
affected)
Secondary
Generalization
Simple
(Level of awareness
unaffected)
Motor
Sensory
Autonomic
Psychic
Non-Convulsive
Absence
Atonic
Convulsive
Myoclonic
Clonic
Tonic
Tonic-Clonic
166
SPELL/SEIZURE: Secondary Organic
Spell/Seizure
(Primary)
Epileptic seizure
Provoked Recurrence
(Secondary)
seizure/other
Secondary Organic Other
Febrile Infection
Sepsis
Encephalitis
Meningitis
Metabolic
Hypoglycemia
Hyperglycemia
Hypocalcemia
Hyponatremia
Uremia
Alcohol
Withdrawal
Drug
Overdose
Liver Failure
Vascular
Injury
Intracranial
Hemorrhage
Subarachnoid
Hemorrhage
Subdural
Hemorrhage
Ischemic
Stroke
Degenerative
Dementia
Structural
Congenital
Abnormality
Neoplasm
Arteriovenous
Malformation
Pregnancy
Eclampsia
167
SPELL/SEIZURE: Other
Spell/Seizure
(Primary)
Epileptic seizure
Provoked Recurrence
(Secondary)
seizure/other
Secondary Organic Other
Neurological
Migraine/Auras
Movement Disorders
(Dystonia, Dyskinesia,
Chorea)
Vascular
Cerebrovascular Accident
Syncope
Psychogenic
Panic Disorder
Conversion Disorder
Pseudoseizures
168
MECHANISMS OF PAIN
Pain
Neuropathic
Burning, shooting, gnawing,
aching, lancinating
Nociceptive
Tissue damage
Mixed
Nociceptive / Neuropathic
Central Nervous
System
Peripheral Nervous
System
Somatic
Visceral
(From organ/cavity lining)
Poorly localized, crampy, diffuse,
deep sensation
Post-Herpetic Neuralgia
Neuroma
Neuropathy
Deep
Less well-localized, dull,
longer duration
Superficial
Well-localized, sharp,
short duration
Deafferentation
Loss of sensory input
Phantom Limb
Post-Stroke
Spinal Injury
Sympathetic
Complex Regional Pain
Syndrome
169
HEADACHE: Primary
Headache
Primary
Usually episodic
Secondary
Usually constant
No Pattern In Clusters Other
Primary Cough Headache
Primary Exertional
Headache
Primary Stabbing Headache
Autonomic Cephalgias
Last for minutes to hours,
separated by hours. Sudden onset.
Cluster Headache (Orbital,
Sharp, Autonomic
Dysfunction)
Hemicranial Continua
Unilateral
Migraine (Throbbing/
Pulsating)
Bilateral
Tension/Stress Headache
(Tightening, Band-Like, Dull)
Other
Last for seconds,
separated by minutes to hours.
Trigeminal Neuralgia
(Shooting, Stabbing)
170
HEADACHE: Secondary, with Red Flag Symptoms
Headache
Primary
(Usually episodic)
Secondary
(Usually constant)
Red Flag Symptoms
Systemic symptoms,
Focal neurological signs,
Sudden onset, Old age,
Progressive signs of increased
intracranial pressure. Change in
established headache pattern
No Red Flag Symptoms
Infection
Meningitis
Encephalitis
Vascular
Ischemic
Stroke
Intracranial
Hemorrhage
Arteriovenous
Malformation
Aneurysm
Trauma
Subarachnoid
Hemorrhage
(Thunderclap
Headache)
Autoimmune
Temporal
Arteritis
Metabolic
Pseudotumor
Cerebri
Neoplasm/
Mass
Cerebrospinal
Fluid
Hydro-
cephalus
Cerebrospinal
Fluid Leak
171
HEADACHE: Secondary, without Red Flag Symptoms
Headache
Primary
Usually episodic
Secondary
Usually constant
Red Flag Symptoms
Systemic symptoms,
Focal neurological signs,
Sudden onset, Old age,
Progressive signs of increased
intracranial pressure.
No Red Flag Symptoms
Chronic
Drugs
Acute
Sinusitis
Dental Abscess
Glaucoma
Analgesic Induced
Headache
Substance Withdrawal
172
BACK PAIN
Back Pain
Always assess for red flags.
If no red flags assess after 6 weeks.
Acute/Subacute +
Red Flags
<6 Weeks
Fracture
Cauda Equina
Syndrome
Tumor/Infection
Chronic/Acute After 6
Weeks + No Red Flags
>6 Weeks
Unresolved Radicular
Symptoms
Spondyloarthropathies
or Osteoarthritis
Myelopathic
173
DYSARTHRIA
Dysarthria
Motor Neuron Disease
Lesions of Cranial Nerves
VII, IX, X, XII
Myasthenia Gravis
Muscular Dystrophy
Lower Motor Neuron
Slow, Low Volume, Breathy Speech.
Tongue and Facial Atrophy.
Fasciculations.
Ataxic (Cerebellar)
Irregular Rhythm and Pitch
Spinal-Cerebellar Ataxia
Multiple Sclerosis
Alcohol
Tumor
Paraneoplastic Disorder
Extra-Pyramidal
Rapid, Low Volume,
Monotone Speech
Parkinson's Disease
Upper Motor Neuron
Slow, strangulated, harsh voice.
Positive jaw jerk. Hyperactive gag
reflex. Emotional lability.
Bilateral Lacunar Internal
Capsule Strokes
Multiple Sclerosis
Amyotrophic Lateral
Sclerosis
174
APHASIA: Fluent
Aphasia
Fluent
Grammatically correct, but
nonsensical & tangential.
Phonemic & semantic paraphasias
Non-Fluent
Agrammatic, hesitant,
but substantive communication
Impaired Repetition Intact Repetition
Impaired
Comprehension
Wernicke's Aphasia
Intact Comprehension
Conduction Aphasia
Anomic Aphasia
Impaired
Comprehension
Transcortical Sensory
Aphasia
175
APHASIA: Non-Fluent
Aphasia
Fluent
Grammatically correct, but
nonsensical & tangential.
Phonemic & semantic paraphasias
Impaired Repetition
Non-Fluent
Agrammatic, hesitant,
but substantive communication
Intact Repetition
Impaired
Comprehension
Global Aphasia
Broca's Aphasia
Transcortical Motor
Aphasia
Impaired
Comprehension
Mixed Transcortical
Aphasia
176
PERIPHERAL WEAKNESS
Complaint of Weakness
No Objective Weakness Objective Weakness
Sensory Changes
Upper and Lower Motor
Neuron
Lower Motor Neuron
Decreased tone and reflexes
No Babinski reflex
Upper Motor Neuron
Increased tone and reflexes
Babinski reflex
No Sensory Changes
Cardio-Pulmonary Disease
Anemia
Chronic Infection
Malignancy
Depression
Deconditioning
Arthritis
Fibromyalgia
Endocrine Disease
Amyotrophic Lateral Sclerosis
Cervical Myeloradiculopathy
Syrinx
Neuromuscular Junction
Fatigability, Variability, Oculomotor
Myasthenia Gravis
Lambert-Eaton Myasthenic
Syndrome
Botulism
Congenital
Myopathy
Typically proximal muscle involvement
Elevated creatinine kinase
Eg:
Polymyositis
Duchenne Muscular Dystrophy
Statin Toxicity
Dermatomyositis
Viral Infection
Motor Neuron and Motor
Neuropathy
Atrophy, Fasciculations, Hyporeflexia
Lead Toxicity
Progressive Muscular Atrophy
Hodgkin's Lymphoma
Polio
Multifocal Motor Neuropathy
Spinal Muscular Atrophy
See Peripheral Weakness:
Sensory Changes scheme
177
PERIPHERAL WEAKNESS: Sensory Changes
Objective Lower Motor Neuron Weakness
Sensory Changes No Sensory Changes
Follows Distribution
Does Not Follow
Distribution
Polyneuropathy
(Length dependent)
Diabetes
Nutrition
Alcohol
Toxin
Paraproteinemic
Inherited
Inflammation
Mono-
neuropathy
Radiculopathy
Disc
Spondylosis
Tumor
Infection
Mononeuritis
Multiplex
Vasculitis
Diabetes
Plexopathy
Brachial Neuritis
Diabetes
Tumor
Poly-
Radiculopathy
Spondylysis
Chronic
Inflammatory
Demyelinating
Polyneuropathy
Neoplasm
Infection
Compression
Carpal Tunnel
Ulnar
Peroneal
Radial
Other
Trauma
Tumor
Ischemia
178
STROKE: Intracerebral Hemorrhage
Stroke
Intracerebral Hemorrhage Subarachnoid Hemorrhage Ischemia
Hypertension
Essential Hypertension
(Aneurysm)
Drugs (Cocaine,
Amphetamines)
Vessel Disease
Amyloid Angiopathy
Vascular Malformation
Aneurysm
Vasculitis
Other
Trauma
Bleeding Diathesis
Hemorrhage into tumors
Hemorrhage into infarct
179
STROKE: Subarachnoid Hemorrhage
Stroke
Vessel Disease
Aneurysm
Vascular Malformation
Other
Bleeding Diathesis
Trauma
Drug Use
180
STROKE: Ischemia
Stroke
Thrombosis
Atherosclerosis, Arterial dissection,
Fibromuscular dysplasia
Embolus Systemic Hypoperfusion
Cardiac
Output
Reduction
Myocardial
Infarction
Pulmonary
Embolus
Pericardial
Effusion
Shock
Pump Failure
Cardiac Arrest
Arrhythmias
Ascending
Aorta
Unknown Small Vessel
Lacunar
Heart
Left Ventricle
Left Atrium
Valve
Atrial
Fibrillation
Bacterial
Endocarditis
Myocardial
Infarction
Large Vessel
181
UNINTENTIONAL WEIGHT LOSS IN THE ELDERLY
Weight Loss
Subacute Acute
Neuropsychiatric
Impairment
Depression
Dementia
Delirium
Acute Presenting As
Subacute
Impaired
Functioning
Physical
Oral Causes
Impaired Swallowing
Poor Dentition
Altered Taste
Active Disease Iatrogenic
Drugs
Decompensation of
Chronic Disease
Congestive Heart
Failure
End-Stage Renal
Disease
Chronic Obstructive
Pulmonary Disease
Hepatic Failure
Arthritis
Psychological or
Social Stress
Isolation
Grief
Financial
Abuse/Neglect
182
URINARY INCONTINENCE
Urinary Incontinence
Transient
(NO DIAP(P)ERS)
Neurologic - stroke,
Parkinson's, Alzheimer's
Obesity
Delirium/confusion
Infection - urinary tract
Atrophy - vaginitis,
urethritis
Pharmacologic -
diuretics,
benzodiazepines,
caffeine,
antidepressants,
narcotics, estrogen
Psychiatric - depression
Excess urine output -
Congestive heart failure,
hyperglycemia
Restricted mobility
Stool impaction/
constipation
Persistent
Stress
Impaired sphincter
closure
Involuntary
Leak with effort
Weak Pelvic
Floor
Impaired
Sphincter
Increase
Urethral
Mobility
Cough,
Sneeze, Laugh
Urge
Overactive detrusor
Involuntary
Leak preceded
by urgency
Neurologic
Stroke,
Parkinson's,
Alzheimer's
Non-neuroloigic
Bladder
Stone/
Carcinoma,
Cystitis,
Bladder Outlet
Obstruction
Mixed
Stress and urge
Overflow Functional
Normal function
of lower urinary
tract
Chronic
functional
impairment
physical,
cognitive, or
mood factors
+/-
Environmental
Barriers
Impaired
Detrusor
Contraction
Spinal Cord
Trauma/Tumor
Cauda Equina
Syndrome
Disc
Compression
Autonomic
Neuropathy
Bladder Outlet
Obstruction
Benign Prostate
Hypertrophy
Prostate
Cancer
Urethral
Stricture
Pelvic Organ
Prolapse
183
Obstetrical & Gynecological Presentations
Prenatal Screening Tests 185
Bleeding in Pregnancy: <20 Weeks 186
Bleeding in Pregnancy: 2nd and 3rd
Trimesters 187
Recurrent Pregnancy Loss 188
Growth Discrepancy:
Small for Gestational Age/Intrauterine
Fetal Growth Restriction 189
Growth Discrepancy:
Non-Reassuring Fetal Status
(Fetal Distress) 191
Abnormal Fetal Heart Rate Tracing 192
Postpartum Hemorrhage 193
Abnormal Genital Bleeding 194
Vaginal Discharge 195
Amenorrhea: Primary 196
Amenorrhea: Secondary 197
Acute Pelvic Pain 198
Chronic Pelvic Pain 199
Infertility: Female 200
Infertility: Male 201
Ovarian Mass 202
Pelvic Mass 203
Pelvic Organ Prolapse 204
Breast Disorders 205
184
Student Editors
Vera Krejcik (Section Editor)
Mia Steiner
Maria Wu
Shaina Lee
Kathy Truong
Faculty Editors
Dr. Ronald Cusano
Dr. Heather Baxter
Dr. Dorthy Igras
Dr. Clinton Chow
Dr. Magali Robert
Dr. Calvin Greene
Dr. Maire Duggan
Dr. Barbara Walley
185
First Trimester
(0-12 Weeks)
Dating U/S
Nuchal Translucency and Nasal
Bone to assess risk of Trisomy
13, 18, 21
Chorionic Villous Sampling (10-
12 weeks) for Chromosomal
Abnormalities and Genetic
Disorders
Lab Work (Beta-hCG, CBC,
ABO/Rh Antibodies, HBsAg,
Syphilis Serology, Rubella IgG
Varicella, HIV)
Gestation Diabetes Screen if
Risk Factors Present
Second Trimester
(12-28 Weeks)
Gestational Diabetes Screen
(50 g Oral Glucose Challenge) at
24-28 weeks
Amniocentesis (14-16 weeks)
Maternal Serum Screen
(MSAFP, Estriol or uE3, Beta-
hCG to assess risk of Trisomy
18,21 and Neural Tube Defects
in patients without first trimester
screen)
Detailed 18-20 Weeks U/S (For
Dating, Number of Fetuses,
Placental Location and Anatomic
Survey)
Third Trimester
(28-40 Weeks)
Fetal Movement Counts (> 6
Movements in 2 Hours)
Rh Antibody Screen if Indicated
Group B Streptococcus Screen
(35-37 weeks)
Confirm Fetal Presentation
Prenatal Screening
PRENATAL SCREENING TESTS
186
BLEEDING IN PREGNANCY: <20 Weeks
Bleeding in Pregnancy
< 20 Weeks Second / Third Trimester
Hemodynamically Unstable - Do ABCDE's
Obtain a Beta-hCG
Not Hemodynamically Stable
Ectopic Pregnancy
Spontaneous Incomplete Abortion
Hemodynamically Stable
Bleeding from the Os
Cervix Open Cervix Closed
No IUP on TV U/S
No Ectopic
Pregnancy on U/S
Ectopic Pregnancy
on U/S
Beta-hCG > 1500
Ectopic Likely
Beta hCG < 1500
Beta hCG doubled at 72 hr
Viable pregnancy - monitor for ectopic or
IUP (implantation bleed)
Beta hCG NOT
doubled at 72 hr
Ectopic pregnancy or failed pregnancy
Not Bleeding from the Os
Cervical Polyp/Cervicitis
Cervical/Vaginal Neoplasia
Vaginal Laceration
IUP on TV U/S
Threatened
Abortion
Gestational
Trophoblastic
Disease (Grape-
Like Vesicles)
Not Passing
Tissue and Clots
Missed Abortion
Inevitable Abortion
Passing Tissue
and Clots
Complete Abortion
Incomplete
Abortion
Ectopic Pregnancy
187
BLEEDING IN PREGNANCY: 2
nd
and 3
rd
Trimesters
Bleeding in Pregnancy
< 20 Weeks Second / Third Trimester
Hemodynamically Unstable - Do ABCDE's
Do not perform Digital Examination until
the placental location is known
Hemodynamically Stable Not Hemodynamically Stable
Bleeding from the Os Not Bleeding from the Os
Cervical Polyp/Cervicitis
Cervical/Vaginal Neoplasia
Vaginal Laceration
Painful
Abruption
Uterine Rupture
Painless
Placenta Previa
Vasa Previa
188
RECURRENT PREGNANCY LOSS
Maternal
Recurrent Pregnancy Loss
Fetal
2 3 consecutive spontaneous abortions
Genetic
Medical Anatomic
Genetic
Maternal Age
Maternal/Paternal
Chromosome
Abnormality
Cervix
Incompetent Cervix
(Second Trimester)
Autoimmune
Antiphospholipid
Antibody Syndrome
Lupus
Anticoagulant
Medical
Diabetes
Hyperthyroidism
Smoking
Drugs
Alcohol
Maternal Infection
Uterus
Fibroid
Congenital Anomaly
189
GROWTH DISCREPANCY: Small For Gestational Age /
Intrauterine Fetal Growth Restriction
Growth Discrepancy
Large for Gestational Age
(Growth > 90
th
Percentile)
Small for Gestational Age
(Growth < 10
th
Percentile)
Maternal Factors Placental Factors
Chromosomal
Abnormalities
Aneuploidy Trisomy 13/18
Chromosomal Deletions
Mosaicism
Imprinting
Genetic Mutations
Multiple Gestation TORCH Infections
Confined Placental
Mosaicism (Rare)
Placental
Malformations
Vasa Previa
Placental Abruption
Placental Ischemia/
Infarctions
Placenta Previa
Chronic Insufficiency
Iatrogenic
Warfarin
Folic Acid Antagonists
Diminished Caloric
Intake
Malnutrition
Maternal Hypoxemia
Pulmonary Diseases
Chronic Anemia
High Altitude
Cigarette Smoking
Fetal Factors
Medical Conditions
Decreasing
Uteroplacental Flow
Gestational Hypertension/
Pre-eclampsia
Renal Insufficiency
Diabetes
Autoimmune Disorders
(e.g. SLE, Antiphospholipid
Syndrome)
190
GROWTH DISCREPANCY: Large For Gestational Age
Growth Discrepancy
(Growth > 90
th
Percentile for GA)
Small for Gestational Age
(Growth < 10
th
Percentile for GA)
Maternal Factors
Multiparity
Previous history of Large for
Gestational Age Fetus
Aboriginal, Hispanic, and Caucasian
Races
Maternal Comorbidities (e.g.
Diabetes, Obesity)
Excessive weight gain over course of
pregnancy (>40 lbs)
Fetal Factors
Male Infant
Prolonged Gestation (>41 weeks)
Genetic Disorder (e.g. Sotos
Syndrome, Beckwith-Wiedemann
Syndrome, Weaver's Syndrome)
COMPLICATIONS
Obstetrical (birth injury): shoulder dystocia,
brachial plexus injury, clavicular fracture,
cerebral palsy secondary to hypoxia
Neonatal conditions: hypoglycemia,
polycythemia, hyperbilirubinemia, asphyxia
191
NON-REASSURING FETAL STATUS (FETAL DISTRESS)
Fetal Distress
Decreased Maternal
Arterial O
2
Tension
Smoking
Hypoventilation
Decreased Maternal O
2
Carrying Capacity
Anemia
Carboxyhemoglobin
Decreased Uterine
Blood Flow
Hypotension
Anesthesia
Maternal Poisoning
Maternal Medical
Conditions
Fever
Vasculopathy
Hyperthyroidism
Maternal Factors Uteroplacental Factors Fetal Factors
Excessive Uterine
Activity
Induction of Labor
Placental Abruption
Uteroplacental
Dysfunction
Placental Abruption
Placental Infarction
Chorioamnionitis
Postdates Pregnancy
Cord Compression
Oligohydramnios
Cord Prolapse
Cord Entanglement
Decreased Fetal O
2
Carrying Capacity
Fetal Anemia
Carboxyhemoglobin
Intrauterine Growth
Retardation
Prematurity
Fetal Sepsis
192
Abnormal Fetal Heart Rate Tracing
ABNORMAL FETAL HEART RATE TRACING
Fetal Bradycardia
Hypoxia
Fetal Heart Block
Decreased Maternal O
2
Carrying Capacity
Anemia
Carboxyhemoglobin
Decreased Uterine
Blood Flow
Hypotension
Anesthesia
Maternal Poisoning
Maternal Medical
Conditions
Fever
Vasculopathy
Hyperthyroidism
Baseline Abnormality Variability Abnormality FHR Decelerations
Excessive Uterine
Activity
Induction of Labor
Placental Abruption
Uteroplacental
Dysfunction
Placental Abruption
Placental Infarction
Chorioamnionitis
Postdate Pregnancy
Cord Compression
Oligohydramnios
Cord Prolapse
Cord Entanglement
Decreased Fetal O
2
Carrying Capacity
Fetal Anemia
Carboxyhemoglobin
Intrauterine Growth
Retardation
Prematurity
Fetal Sepsis
193
POSTPARTUM HEMORRHAGE
Thrombin (1%)
Thrombocytopenia
Idiopathic
Thrombocytopenic
Purpura
Thrombotic
Thrombocytopenic
Purpura
HELLP Syndrome
(Hemolysis, Elevated
Liver enzymes, Low
Platelets)
Disseminated
Intravascular Coagulation
Anticoagulation Agents
(ie. Tinzaparin)
Von Willebrand's Disease
Uterine Atony (70%)
Overdistention of Uterus
(e.g. Multiple Gestation,
Polyhydramnios, Fetal
Macrosomia, Grand
Multiparity)
Uterine Infection (e.g.
Chorioamnionitis,
Endomyometritis)
Uterine Fatigue
(Prolonged/Induced
Labor)
Drugs Uterine Relaxants
(e.g. Nifedipine,
Magnesium Sulfate,
NSAIDs)
Trauma (20%)
Uterine Rupture
Uterine Perforation/
Laceration
Cervical Laceration (e.g.
Forceps/Vacuum Delivery)
Vaginal Laceration/
Hematoma
Vulvar Laceration (e.g.
Episiotomy)
Remnant Tissue (10%)
Retention of Placenta
Placenta Accreta/Increta/
Percreta
Retained Blood Clots
Postpartum Hemorrhage
Blood Loss: > 500 mL post vaginal delivery OR > 1000 mL post Cesarean section
194
ABNORMAL GENITAL BLEEDING
Abnormal Genital Bleeding
Pregnant Not Pregnant
Non-Gynecologic
Medical (e.g. Coagulopathy,
Liver Disease, Renal
Disease)
Drugs
Gynecologic
Vulva
Trauma
Neoplasm
Vulvar Dystrophy
Infection
Uterus
Anovulatory
Fibroid
Trauma
Neoplasm
Exogenous Hormones
Infection
Cervix
Polyp
Trauma
Neoplasm
Infection
Vagina
Trauma
Neoplasm
Atrophy
Infection
See Bleeding in Pregnancy
Scheme
195
VAGINAL DISCHARGE
Vaginal Discharge
Inflammatory Infectious Neoplastic
Endometrium
Cervix
Vulva
Vagina
Systemic
Crohn's disease
Collagen disorder
Dermatologic
Toxic Shock
Syndrome
Vulvovaginitis
Bacterial vaginosis
Candidiasis
Trichomoniasis
Local
Chemical irritant
Douching
Atrophic vaginitis
Foreign body
Sexually
Transmitted
Infection
Chlamydia
trachomatis
Neisseria
gonorrheae
196
AMENORRHEA: Primary
Primary
No onset of menarche by age 16
Secondary
Absence of menses for three months /
Three cycles
Amenorrhea
Congenital Outflow
Tract Anomalies
Imperforate Hymen
Transverse Vaginal
Septum
Vaginal Agenesis (Mayer-
Rokitansky-Kster-Hauser
Syndrome)
Cervical Stenosis
Ovarian Failure
High FSH
46, XX Gonadal
Dysgenesis
Turner Syndrome
Savage Syndrome
(Ovarian Resistance)
Polycystic Ovarian
Syndrome
Gonadal Agenesis
46, XY
Swyer Syndrome
Androgen Insensitivity
5-Alpha Reductase
Deficiency
17- Hydroxylase Defect
Central
Low FSH
Gonadal Agenesis
Functional (e.g. Nutrition,
Stress, Weight Loss,
Athletics)
Kallman's Syndrome
Constitutional Growth
Delay
Pituitary
Surgery, Irradiation
Tumor, Infiltration
Hyperprolactinemia
Hypothyroid
197
AMENORRHEA: Secondary
Primary
No onset of menarche by age 16
Secondary
Absence of menses for three months /
Three cycles
Amenorrhea
Outflow Tract
Obstruction
Asherman's Syndrome
Cervical Stenosis
Ovarian Disease
Hypothalamic
Negative Progesterone Challenge,
Low FSH,Low Estrogen
Functional (e.g. Nutrition,
Weight loss, Stress,
Exercise, Illness)
Organic (e.g. Mass,
Infiltration, Sheehan's
Syndrome, Infarction)
Pituitary Disease
Other
Primary Hypothyroidism
Adenoma
Polycystic Ovarian
Syndrome
Positive Progesterone Challenge,
Normal FSH, Normal Prolactin,
Chaotic Menstruation History
High FSH
Menopause
Premature Ovarian Failure
(<35 years old, e.g.
Autoimmune,
Chromosomal, Iatrogenic)
High Prolactin
Prolactinoma
Hypothalamic Dysfunction
(e.g. Mass, Anti-dopamine
Drugs)
Chest Wall Irritation
Periphery (e.g. Ectopic
secretion)
Rule out pregnancy (-hCG)
198
ACUTE PELVIC PAIN
Acute Pelvic Pain
Gynecologic Non-Gynecologic
Genitourinary
Gastrointestinal
Musculoskeletal
Pregnant Not Pregnant
Fallopian Tube
Pelvic Inflammatory
Disease
Tubal Ovarian
Abscess
Torsion
Endometriosis
Intrauterine
Miscarriage
Labour
Abruption
Molar Pregnancy
Uterus
Fibroid
Pyometra
Hematometra
Adenomyosis
Endometriosis
Ovary
Tubal Ovarian
Abscess
Cyst
Torsion
Endometriosis
Ovulation Pain
Extrauterine
Ectopic
199
CHRONIC PELVIC PAIN
Gynecologic
Endometriosis
Chronic Pelvic Inflammatory
Disease
Dysmenorrhea
Adenomyosis
Ovarian Cyst
Adhesions
Non-Gynecologic Comorbidities
Somatization
Sexual/Physical/Psychological
Abuse
Depression/Anxiety
Abdominal Wall Pain
Chronic Pelvic Pain
> 6 Months in Duration
Gastrointestinal
Inflammatory Bowel Disease
Constipation
Neoplasm
Non-Gynecologic
Interstitial Cystitis
Urinary Retention
Co-Morbidities
Myofascial Trigger
Injury
200
INFERTILITY: Female
Male (35%)
Unexplained (15%) Female (50%)
Infertility
Failure to conceive following > 1 year of unprotected sexual intercourse
Uterus
HSG or SIS
Fibroids/polyps
Asherman's Syndrome
Congenital Anomalies
Adenomyosis
Unfavourable cervical
mucous
Cervical stenosis
Fallopian Tube
HSG or SIS or laparoscopy
Pelvic Inflammatory Disease
Endometriosis
Adhesions
Previous Tubal Pregnancy
Ovary
Ovulation: Midluteal Serum
Progesterone or Urine LH Testing
Ovarian Reserve: Day 3
Estradiol + FSH
Decreased FSH
Polycystic Ovarian Syndrome
Obesity
Normal FSH
Premature Ovarian Failure
Natural Aging
Turner's Syndrome
Increased FSH
Weight Loss/Malnutrition
Excessive Exercise
Stress/Psychosis
Systemic Disease
Hypothalamic
Hypothyroidism
Hyperprolactinemia
Tumors (e.g. Prolactinoma)
Hypopituitarism
201
INFERTILITY: Male
Male (35%) Unexplained (15%) Female (50%)
Infertility
Failure to conceive following > 1 year of unprotected sexual intercourse
Sexual Dysfunction
See Sexual Dysfunction Scheme
Sperm Transport
Azoospermia (vasectomy)
Cystic Fibrosis
Post-infectious Obstruction
Ejaculatory Duct Cysts (e.g.
prostate)
Kartagener Syndrome
Sperm Motility
Abnormal Semen Analysis
Sperm Production
(Non-obstructive azoospermia)
Low Testosterone
Pre-Testicular
(Hypogonadotrophic
hypogonadism)
Low FSH/LH
Kallman's Syndrome
Suppression of
Gonadotropins (e.g.
Hyperprolactinemia,
Drugs, Tumor, Infection,
Trauma)
Anabolic Steroids
Testicular
(Sperm production problem)
High FSH/LH
Genetic abnormality (e.g.
Klinefelter's)
Cryptorchidism
Varicocele
Mumps Orchitis
Radiation, Drugs,
Trauma, Torsion
202
OVARIAN MASS
Ovarian Mass
Benign Neoplasms Malignant Neoplasms Functional
Follicular
Corpus Lutein Cyst
Theca Lutein Cyst
Hyperplastic
Polycystic Ovary
Endometrioid Cyst
Stromal
Granulosa-Theca Cell
Tumor
Metastases
Krukenberg
(Gastrointestinal)
Breast
Germ Cell
Dysgerminoma
Immature Teratoma
Epithelial
Serous
Cystadenocarcinoma
Mucinous
Cystadenocarcinoma
Sex Cord Stromal
Fibroma
Thecoma
Granulosa Cell Tumor
Germ Cell
Mature Teratoma (may
be cystic)
Gonadoblastoma (can
become malignant)
Epithelial
Serous Cystadenoma
Mucinous Cystadenoma
203
PELVIC MASS
Gynecologic
Pelvic Mass
Non-Gynecologic
Do Pelvic U/S
Genitourinary
Distended Bladder
Bladder Cancer
Pelvic Kidney
Ovary
See Ovarian Mass
Scheme
Fallopian Tube
Ectopic Pregnancy
Paratubal Cyst
Pyosalpinx
Hydrosalpinx
Neoplasm
Gastrointestinal
Appendiceal
Abscess
Diverticular
Abscess
Diverticulosis
Rectal/Colon
Cancer
Uterus
Symmetric
Pregnancy
Adenomyosis
Endometrial Cancer
Hematometra
Pyometra
Asymmetric
Leiomyomata
Leiomyosarcoma
204
PELVIC ORGAN PROLAPSE
Pelvic Organ Prolapse
Herniation of one or more pelvic organs
Risk Factors: Genetics, Multiparity, Operative vaginal delivery,
Obesity, Increasing age, Estrogen deficiency,
Pelvic Floor neurogenic damage (i.e. surgical),
Strenuous activity (i.e. weight bearing)
Bowel/Rectum
Defecatory Symptoms
Enterocele (i.e. Anterior,
Posterior)
Rectocele
Uterus
Sensation of object Falling out of
vagina, Possible Lower Back Pain
Uterine Prolapse
Cervical Prolapse
Vaginal Apex
Pelvic Pressure, Urinary Retention,
Stress Incontinence
Vaginal Vault Prolapse
Bladder
Slow Urinary Stream, Stress
Incontinence, Bladder Neck
Hypermobility on Q-Tip Test
Cystocele
Cystourethrocele
205
BREAST DISORDERS
Breast Disorders
Pathologic
Drugs
Decreased
Testosterone
Increased
Estrogen
Idiopathic
Malignant Benign Physiologic
Newborn
Adolescence
Aging
Non-Lactational
Subareolar
Abscess
Acute Mastitis
Lactational
Mastitis
Abscess
Breast Infection Breast Mass Gynecomastia
Non-Invasive
Ductal Carcinoma
in situ
Lobular
Carcinoma in situ
Invasive
Ductal Carcinoma
Lobular
Carcinoma
Tubular
Carcinoma
Medullary
Carcinoma
Papillary
Carcinoma
Mucinous
Carcinoma
Nodular
Fibrocystic
Change
Benign
Gross Cyst
Galactocele
Fibroadenoma
206
207
Dermatologic Presentations
Primary Skin Lesions 209
Secondary Skin Lesions 210
Comedone 211
Vascular Lesions 212
Skin Rash: Eczematous 213
Skin Rash: Papulosquamous 214
Skin Rash: Vesiculobullous 215
Skin Rash: Pustular 216
Skin Rash: Reactive 217
Hypopigmentation 218
Hyperpigmentation 219
Skin Ulcer by Etiology 220
Skin Ulcer by Location: Head/Neck 221
Skin Ulcer by Location: Oral Ulcers 222
Skin Ulcer by Location: Trunk/Sacral
Region 223
Skin Ulcer by Location: Genitals 224
Skin Ulcer by Location:
Lower Legs/Feet 225
Hair Loss (Alopecia): Localized 226
Hair Loss (Alopecia): Diffuse 227
Nail Disorders: Primary Dermatologic
DIsease 228
Nail Disorders: Systemic Disease 229
Nail Disorders: Systemic Disease -
Clubbing 230
(Oral Cavity) 231
Pruritis: Primary Skin Lesion 232
208
Pruritis: No Primary Skin Lesion 233
Physiologic Changes 234
Specific Skin Condition 235
Genital Lesion 236
Burns 237
Student Editors
Jennifer Rodrigues (Section Editor)
Arjun Rash
Sarah Surette
Joanna Debosz
Safiya Karim
Beata Komierowski
Dave Campbell
Yang Zhan
Faculty Editors
Dr. Laurie Parsons
209
MORPHOLOGY OF SKIN LESIONS: Primary Skin Lesions
Primary Skin Lesion
Initial lesion not altered by trauma,
manipulation (rubbing, scratching),
complication (infection),
or natural regression over time
Skin Lesion
Secondary Skin Lesion
Lesion that develops from trauma,
complication (infection) of initial lesion,
or develops naturally over time
Flat Elevated
Macule (> 1 cm diameter)
Patch (> 1 cm diameter)
Fluid-Filled OR
Semi-Solid-Filled
Cyst
Fluid-Filled Solid
Non-Purulent Fluid
Vesicle (> 1 cm diameter)
Bulla (> 1 cm diameter)
No Deep Component
Papule (> 1 cm diameter)
Plaque (< 1 cm diameter)
Deep Component
Nodule (13 cm diameter)
Tumor (> 3 cm diameter)
Purulent
Pustule
Firm/Edematous Transient/Itchy
Wheal/Hive (Urticaria)
210
MORPHOLOGY OF SKIN LESIONS: Secondary Skin Lesions
Primary Skin Lesion
Initial lesion not altered by trauma,
complication (infection),
or natural regression over time
Skin Lesion
Secondary Skin Lesion
Lesion that develops from trauma,
complication (infection) of initial lesion,
or develops naturally over time
Crust/Scab (dried serum, blood, or
pus overlying lesion)
Scale (dry, thin or thick flakes of
skin overlying lesion
Lichenification (thickened skin with
accentuation of normal skin lines)
Hypertrophic Scar (within
boundary of injury)
Keloid Scar (extends beyond
boundary of injury)
Elevated
Atrophic Scar (fibrotic replacement
of tissue at site of injury)
Ulcer (complete loss of epidermis
extending into dermis or deeper;
heals with scar)
Erosion (partial loss of epidermis
only; heals without scar)
Fissure (linear slit-like cleavage of
skin)
Excoriation/Scratch (linear erosion
induced by scratching)
Depressed
211
COMEDONE
Comedone
Exposed to Air
Open Comedone (Blackhead)
Not Exposed to Air
Closed Comedone (Whitehead)
Collection of sebum and keratin in
duct of pilosebaceous unit
212
VASCULAR LESIONS
Vascular Lesion
Blanches with Pressure
Small, dilated superficial blood vessels
Telangiectasia
Does Not Blanch with Pressure
Erythematous or Violaceous Discolorations of
skin due to extravasation of RBCs in dermis
Petechiae < 0.2 cm diameter
Purpura 0.2 - 1 cm diameter
Ecchymosis > 1 cm diameter
Acquired
Vasculitis
Congenital
Hemangioma
213
SKIN RASH: Eczematous
Skin Rash
Reactive
Reactive Erythemas with
various morphology
Papulosquamous
Erythematous or violaceous
papules and plaques with
overlying scale
Vesiculobullous
Blisters containing
non-purulent fluid
Pustular
Blisters containing
purulent fluid
Eczematous
Pruritic/Scaly/
Erythematous lesions
Usually poorly demarcated
Contact
Dermatitis
Well-Demarcated
Erythema, Papules,
Vesicles, Erosions,
Scaling confined to areas
of contact with a
substance
Seborrheic
Dermatitis
Yellowish-Red Plaques
with greasy distinct
margins on Scalp/Face/
Central Chest Folds
Stasis Dermatitis
Erythematous Eruption of
lower legs, Secondary to
Venous Insufficiency/+/-
Pigmentation, Edema,
Varicose Veins,
Venous Ulcers
Dyshidrotic
Eczema
(Pompholyx)
Deep-Seated Tapioca-like
Vesicles on Hands/Feet/
Sides of Digits
Nummular
Dermatitis
(Discoid Eczema)
Coin-Shaped (Discoid)
Erythematous Plaques.
Usually on lower legs
Atopic Dermatitis
(Eczema)
Erythematous Papules
and Vesicles (Acute) or
Lichenification (Chronic).
Often associated with
Asthma and
Allergic Rhinitis
Age Dependent
Distribution:
Infants: Scalp/Face/
Extensor Extremities
Children: Flexural Areas
Adults: Flexural Areas/
Hands/Face/Nipples
Irritant
Rapid onset,
Requires high
concentrations of agent,
May occur in anyone
Allergic
Delayed onset
(12-72 hours),
Very low concentrations
sufficient,Occurs only in
those sensitized
214
SKIN RASH: Papulosquamous
Discoid Lupus
Erythematous
Scarring and/or Atrophic
Red/Purple Plaques with
White Adherent Scale on
Sun-exposed areas
Pityriasis Rosea
Oval, Tannish-Pink or
Salmon-Colored Patches,
Plaques with Scaling
Border in Christmas
Tree Pattern on Trunk,
Begins with Large Lesion
Patch (Herald Patch)
Tinea
(Ringworm)
Annular (Ring-Shaped)
Lesion with Elevated
Scaling, Red Border,
Central Clearing
Secondary
Syphilis
Red-Brown or
Copper-Colored Scaling
Papules and Plaques on
Palms/Soles
Lichen Planus
Purple, Pruritic, Polygonal,
Planar (Flat-Topped)
Papules on Wrists/Ankles/
Genitals (Especially penis)
Wickham's Striae
Koebner's Phenomenon
Psoriasis
Well-Demarcated
Plaques, Thick Silvery
Scale on Elbows & Knees
Auspitz Sign
Koebner's Phenomenon
Skin Rash
Reactive
various morphology
Papulosquamous
overlying scale
Vesiculobullous
Blisters containing
non-purulent fluid
Pustular
Blisters containing
purulent fluid
Eczematous
Pruritic/Scaly/
215
SKIN RASH: Vesiculobullous
Vesicles Fragile/
Easily Ruptured
Intraepidermal Blisters
Possibly Crusts/Erosions
Vesicles NOT Fragile/
Easily Ruptured
Subepidermal Blisters
Tense Intact Blisters
Inflammatory
Pemphigus
Vulgaris
Pemphigus
Foliaceus
Infectious
Varicella Zoster
(Chickenpox)
Herpes Zoster
(Shingles)
Herpes Simplex
Bullous Impetigo
Reaction to
Agent
Contact Dermatitis
Skin Rash
Reactive
various morphology
Papulosquamous
overlying scale
Vesiculobullous
Blisters containing
non-purulent fluid
Pustular
Blisters containing
purulent fluid
Eczematous
Pruritic/Scaly/
Reaction to
Agent
Phototoxic Drug
Eruption
Metabolic
Porphyria
Cutanea Tarda
Diabetic Bullae
(Bullous
Diabeticorum)
Inflammatory
Bullous
Pemphigoid
Mucous
Membrane
Pemphigoid
Dermatitis
Herpetiformis
Bullous Systemic
Lupus
Erythematosus
216
SKIN RASH: Pustular
Infectious
Acneiform
Erythematous Papules
and Pustules on Face
Acne Vulgaris
Comedones +/- Nodules,
Cysts, Scars on
Face & Trunk
Comedones
Absent
Folliculitis
Pustules centered around
Hair Follicles
Impetigo
Pustules with overlying thick
Honey-Yellow Crust
Candidiasis
Beefy Red Erythematous
Patches in Body Folds with
Satellite Pustules at
periphery
Acne Rosacea
Telangiectasia, Episodic
Flushing after sunlight,
Alcohol, hot or spicy
foods & drinks
Perioral Dermatitis
Perioral, Periorbital &
Nasolabial Distribution,
Sparing Vermillion
Borders of Lips
Skin Rash
Reactive
various morphology
Papulosquamous
overlying scale
Vesiculobullous
Blisters containing
non-purulent fluid
Pustular
Blisters containing
purulent fluid
Eczematous
Pruritic/Scaly/
217
SKIN RASH: Reactive
Erythema Multiforme
Target Lesions possibly with
Macules, Papules, Vesicles
and/or Bullae on Palms, Soles,
Mucous Membranes
Urticaria
Firm/Edematous
Papules & Plaques that are
transient and itchy
Usually lasts < 24 hours
Erythema Nodosum
Tender or painful
Red Nodules on Shins
Skin Rash
Reactive
various morphology
Papulosquamous
overlying scale
Vesiculobullous
Blisters containing
non-purulent fluid
Pustular
Blisters containing
purulent fluid
Eczematous
Pruritic/Scaly/
218
DISORDERS OF PIGMENTATION: Hypopigmentation
Disorder of Pigmentation
Hypopigmentation Hyperpigmentation
Localized
Discrete Areas
Diffuse
Acquired
Vitiligo (Rare)
Congenital
Tuberous Sclerosis (White
Ash Leaf Macules)
Acquired
Congenital
Generalized hypopigmentation
of hair, eyes, skin
Phenylketonuria
Albinism
Piebaldism
Scale
Tinea Versicolor
Pityriasis Alba
Acquired
Vitiligo
Post-Inflammatory
Hypopigmentation
219
DISORDERS OF PIGMENTATION: Hyperpigmentation
Disorder of Pigmentation
Hypopigmentation Hyperpigmentation
Localized
Discrete Areas
Diffuse
Tanning
Adverse Cutaneous Drug Eruption
Addison's Disease
Hemochromatosis
Porphyria Cutanea Tarda
Other
Congenital
Caf au Lait Macules
(Neurofibromatosis or McCune-
Albright Syndrome)
Congenital Melanocytic Nevi
Acquired
Freckles (Ephelides)
Lentigines
Melasma
Tinea Versicolor (more commonly
hypopigmented)
Post-Inflammatory Hyperpigmentation
220
SKIN ULCER BY ETIOLOGY
Infectious Hematologic
Skin Ulcer
Neoplastic
Squamous
Cell
Carcinoma
Basal Cell
Carcinoma
Melanoma
Mycosis
Fungoides
(Cutaneous
T-Cell
Lymphoma)
Neurological
Diabetic
Neuropathy
Tabes
Dorsalis
(Syphilis)
Factitious
Disorder
Delusions of
Parasitosis
Metabolic
Pyoderma
Gangre-
nosum
Diabetic
Dermopathy
Necrobiosis
Lipoidica
Drugs
Coumadin
Heparin
Bleomycin
Vascular
Arterial
Insufficiency
Venous
Insufficiency
Vasculitis
Physical
Trauma
Pressure
Radiation
Other
Cryo-
globulinemia
Protozoan
Leishmaniasis
Viral
Herpes Simplex
Bacterial
Tuberculosis
Syphilis
Chlamydia
trachomatis
Klebsiella
granulomatis
Fungal
Histoplasmosis
Coccidioido-
mycosis
Cryptococcosis
Hemoglobinopathy
Sickle Cell Anemia
Thalassemia
221
SKIN ULCER BY LOCATION: Head / Neck
Neoplastic
Squamous Cell
Carcinoma
Basal Cell
Carcinoma
Melanoma
Pyoderma
Gangrenosum
Metabolic Vascular
Wegener's
Granulomatosis
Radiation
Other
Lower Legs/Feet Head/Neck
Trunk/Sacral
Region
Genitals Oral
Skin Ulcer
222
SKIN ULCER BY LOCATION: Oral Ulcers
Trunk/Sacral
Region
Genitals Oral
Skin Ulcer
Single Ulcers
Traumatic Ulcer
Angular Ulcer
Aphthous Ulcer
Herpes Simplex
Multiple Acute
Ulcers
Viral Stomatitis
Erythema Multiforme
Acute Necrotizing
Ulcerative Gingivitis
Multiple
Recurrent Ulcers
Aphthous
Stomatitis
Herpes Simplex
Infection
Multiple Chronic
Ulcers
Pemphigus
Vulgaris
Lichen Planus
Lupus
Erythematosus
Bullous
Pemphigoid
223
SKIN ULCER BY LOCATION: Trunk / Sacral Region
Neoplastic
Squamous Cell
Carcinoma
Basal Cell
Carcinoma
Melanoma
Mycosis Fungoides
(Cutaneous T-Cell
Lymphoma)
Other
Trunk/Sacral
Region
Genitals Oral
Skin Ulcer
Physical
Physical
Trauma
Radiation
224
SKIN ULCER BY LOCATION: Genitals
Trunk/Sacral
Region
Genitals Oral
Skin Ulcer
Painless
Primary Syphilis
(Chancre)
Granuloma
Inguinale
Lymphogranuloma
Venereum
Painful
Herpes Simplex
Haemophilus
ducreyi (Chancroid)
Behet's Syndrome
Pemphigus Vulgaris
Lichen Sclerosis
Erosive Lichen
Planus
225
SKIN ULCER BY LOCATION: Lower Legs / Feet
Trunk/Sacral
Region
Genitals Oral
Skin Ulcer
Other Neoplastic
Squamous Cell
Carcinoma
Basal Cell
Carcinoma
Melanoma
Metabolic
Pyoderma
Gangrenosum
Diabetic
Dermopathy
Necrobiosis
Lipoidica
Neurological
Diabetic
Neuropathy
Tabes Dorsalis
(Syphilis)
Vascular
Arterial
Insufficiency
Vascular
Insufficiency
Vasculitis
Physical
Pressure
Trauma
Radiation
226
HAIR LOSS (ALOPECIA): Localized
Hair Loss
Diffuse Localized (Focal)
Scarring
Irreversible Biopsy Required
Non-Scarring
Reversible
Hair Shafts
Intact or Absent
Infectious
Secondary to
Skin Disease
Broken Hair Shafts
Alopecia Areata
Secondary Syphilis
Tinea Capitis
Trichotillomania
Traction Alopecia
Congenital Hair Shaft
Abnormalities
Discoid Lupus
Erythematosus
Lichen Planopilaris
Pseudopelade of Brocq
Alopecia Mucinosa
Keratosis Follicularis
Aplasia Cutis
Tinea Capitis with Kerion
Folliculitis Decalvans
227
HAIR LOSS (ALOPECIA): Diffuse
Hair Loss
Diffuse Localized (Focal)
Scarring
Irreversible Biopsy Required
Lupus Erythematosus
Lichen Planopilaris
Non-Scarring
Reversible
Telogen Effluvium Patterned
Androgenetic Alopecia
Anagen Effluvium
Chemotherapy
Loose Anagen Syndrome
Discrete Patches
Alopecia Totalis (All Scalp
and Facial Hair)
Alopecia Universalis (All
Body Hair)
Stress Related Endocrine Dietary Drugs
Hypothyroidism
Hyperthyroidism
Hypopituitarism
Post-Partum
Iron Deficiency
Zinc Deficiency
Copper Deficiency
Vitamin A Excess
Oral Contraceptives
Hyperthyroid Drugs
Anticoagulants
Lithium
Post-Infectious
Post-Operative
Psychological Stress
228
NAIL DISORDERS: Primary Dermatologic Disease
Nail Plate Abnormality Nail Fold Abnormality
Nail Disorder
Primary Dermatologic
Disease
Systemic Disease
Telangiectasia
SLE
Scleroderma
Dermatomyositis
Thickening
Psoriasis
Onychomycosis
Onychogryphosis
Onycholysis
Psoriasis
Onychomycosis
Inflammation
Erythema/Swelling/Pain
Pitting
Psoriasis
Alopecia Areata
Discolouration
Lateral Only
Ingrown Nail
Proximal &
Lateral
Fungal Culture Oil Drop Sign
Psoriasis
Acute
Trauma/Infection
Acute Paronychia
Chronic
Chronic
Paronychia
Brown/Black
Linear Streak
Junctional/
Melanocytic
Nevus
Malignant
Melanoma Under
Nails
Drug-Induced
White/Yellow-
Brown
Onychomycosis
Green
Pseudomonas
Infection
229
NAIL DISORDERS: Systemic Disease
Nail Plate Abnormality
Nail Fold Abnormality
Telangiectasia
Systemic Lupus Erythematosus
Scleroderma
Dermatomyositis
Nail Bed Abnormality
Nail Disorder
Disease
Systemic Disease
Clubbing
Koilonychia
Spoon-Shaped
Iron Deficiency Anemia
Onycholysis
Plate separating from Bed
Hyperthyroidism
Beau's Lines
Horizontal Grooves
Any systemic disease
severe enough to
transiently halt nail
growth (e.g. Shock,
Malnutrition)
Red Discolouration
Splinter Hemorrhages (Dark
red, thin lines, usually painful)
Bacterial Endocarditis
Trauma
White
Discolouration
Blue Discolouration
Medications
Wilson's Disease
Silver Poisoning
Cyanosis
Terry's NaiIs
Proximal 90%
Liver Cirrhosis
Congestive Heart
Failure
Diabetes Mellitus
Half-and-Half Nails
50%
Uremia
Muehrcke's Lines
Transverse Lines
Nephrotic Syndrome
230
NAIL DISORDERS: Systemic Disease - Clubbing
Nail Plate Abnormality
Nail Fold Abnormality
Telangiectasia
Systemic Lupus Erythematosus
Scleroderma
Dermatomyositis
Nail Bed Abnormality
Nail Disorder
Disease
Systemic Disease
Clubbing
Koilonychia
Spoon-Shaped
Onycholysis
Plate Separating from Bed
Beau's Lines
Horizontal Grooves
Endocrine Disease
Bronchopulmonary
Disease
Cardiovascular
Disease
Gastrointestinal
Disease
Other
Hyperthyroidism
(Grave's Disease)
Bronchiectasis
Chronic Lung
Infection
Lung Cancer
Asbestosis
Cystic Fibrosis
Chronic Hypoxia
Cyanotic Heart
Disease
Inflammatory Bowel
Disease (Crohn's
Disease, Ulcerative
Colitis)
Gastrointestinal
Cancer
Human
Immunodeficiency
Virus
Congenital Defect
231
MUCOUS MEMBRANE DISORDER (Oral Cavity)
Neoplastic
Leukoplakia
Squamous Cell
Carcinoma
Disease
Aphthous Stomatitis
(Recurrent, punched out
ulcers, often preceded by
trauma/emotional stress
Herpetic Gingivostomatitis
Pemphigus Vulgaris
Bullous Pemphigoid
Erythema Multiforme
Stevens-Johnson
Syndrome
Toxic Epidermal
Necrolysis
Systemic Disease
Systemic Lupus
Erythematosus
Inflammatory Bowel
Disease (Ulcerative Colitis
more than Crohn's
Disease)
Behet's Syndrome
Non-Neoplastic
Erosions/Ulcers/
Blisters
White Lesions
Candidiasis
White/Cottage Cheese Like
Plaques/Scrape Off Easily
Lichen Planus
Reticular (Lace-Like)
White Lines & Papules
232
PRURITUS: Primary Skin Lesion
Macules/Papules/Plaques
Xerosis (Dry Skin)
Atopic Dermatitis
Nummular Dermatitis
Seborrheic Dermatitis
Stasis Dermatitis
Psoriasis
Lichen Planus
Infestations (Scabies, Lice)
Arthropod Bites
Vesicles/Bullae
Varicella Zoster (Chickenpox)
Dermatitis Herpetiformis
Bullous Pemphigoid
Wheals/Hives
Urticaria
Pruritus
Primary Skin Lesion No Primary Skin Lesion
233
PRURITUS: No Primary Skin Lesion
Pruritus
Primary Skin Lesion No Primary Skin Lesion
Primary Abnormal Finding
TSH & T4
Hypothyroidism
Hyperthyroidism
Creatinine & BUN
Chronic Renal
Failure/Uremia
Liver Function
Tests/Enzymes
Cholestatic Liver
Disease
Blood Glucose
Diabetes Mellitus
CBC &
Differential
Lymphoma
Leukemia
Polycythemia
Rubra Vera
Essential
Thrombocythemia
Myelodysplastic
Syndrome
Psychiatric
Disease
Delusions of
Parasitosis
234
DERMATOSES IN PREGNANCY: Physiologic Changes
Physiologic Skin Changes
Dermatoses in Pregnancy
Specific Skin Conditions
Pigmentary Other
Striae Distensae (Striae
Gravidarum)
Distal Onycholysis
Subungual Keratosis
Hyperhydrosis
Miliaria
Dyshidrotic Eczema
Hirsutism (face, limbs, and back)
Vascular
Mucous
Membranes
Chadwick's Sign
(Bluish discoloration
of Cervix/Vagina/
Vulva)
Abdomen
Linea Nigra
Other
Hyperpigmentation
of Areolae, Axillae &
Genitalia
Increase in Mole
size & number
Skin
Palmar Erythema
Spider Nevi
Cherry
Hemangioma
(Campbell de
Morgan Spot)
Pyogenic
Granuloma
Face
Melasma
235
DERMATOSES IN PREGNANCY: Specific Skin Condition
Physiologic Skin Changes
Dermatoses in Pregnancy
Specific Skin Conditions
Not Pruritic
Pustular Psoriasis of Pregnancy
Impetigo Herpetiformis
(Burning fiery red Erythematous
Pustules/Fever)
Pruritic
Primary Skin Lesion
Pemphigoid Gestationis
(Erythematous Urticarial
Patches/Plaques that progress to
Vesicles/Bullae, Distribution is
Typically Periumbilical)
Pruritic Urticarial Plaques &
Papules of Pregnancy (PUPPP)
(Usually begins on lower
abdomen and striae)
No Primary Skin Lesion
Intrahepatic Cholestasis of
Pregnancy (Pruritus worse at
night, 3
rd
Trimester)
236
GENITAL LESION
Excoriations
Scabies
Pubic Lice
Vesicles
Herpes Simplex
Papules/Plaques Erosions/Ulcers
Genital Lesion
Elevated Depressed
Painless
Primary Syphilis
(Chancre)
Granuloma Inguinale
Lymphogranuloma
Venereum
Infectious
Molluscum Contagiousum
Human Papilloma Virus
Warts (Condyloma
Acuminata)
Secondary Syphilis
(Condyloma Lata)
Reiter's Syndrome
(Circinate Balanitis)
Non-Infectious Painful
Herpes Simplex
Haemophilus ducreyi
(Chancroid)
Behet's Syndrome
Pemphigus Vulgaris
Lichen Sclerosis
Erosive Lichen Planus
Inflammatory
Lichen Planus
Psoriasis
Non-Infectious
Squamous Cell
Carcinoma in situ
Squamous Cell
Carcinoma
Melanoma
237
BURNS
Physical Agents
Sun Exposure
Heat (Fire/flame, radiation,
scalds)
Electrical (Power wire, lighting)
Chemical Agents
Acid
Alkali
Oxidants (Bleaches, peroxides,
chromates, manganates)
Vesicants (Sulfur and nitrogen
mustards, arsenicals, phosgene
oxime)
Others (White phosphorus,
metals, persulfates, sodium
azide)
Requiring Special Care
Second & Third Degree > 10
20%
Second & Third Degree Face,
Hands, Genitalia, Feet, Joints
Third Degree > 5%
Electrical Burns
Threats to function/cosmesis
Circumferential
Associated with serious illness
Burns
238
239
Musculoskeletal Presentations
Bone Lesion 240
Deformity/Limp 241
Acute Joint Pain 242
Chronic Joint Pain 243
Infectious Joint Pain 244
Inflammatory Joint Pain 245
Vascular Joint Pain 246
Myotomes: Segmental Innervation of
Muscles 247
Pathologic Fractures 248
Guide to Spinal Cord Injury 249
Student Editors
Jonathan Dykeman (Section Editor)
Kate Elzinga
Katy Anderson
Bikram Sidhu
Tara Daley
Faculty Editors
Dr. Marcia Clark
Dr. Sylvain Coderre
Dr. Mort Doran
Dr. Henry Mandin
240
BONE LESION
Multiple Lytic Lesions
Multiple Myeloma
Exostotic
Osteochondroma
Narrow, < 1 mm Margin
Reactive Bone Formation
Broad or Indistinct
Margin &/or Soft Tissue
Invasion
Bone Lesion on X-Ray
Rule Out Osteomyelitis & Secondary Metastases
Mass? Bone pain at rest? Constant, deep, achy and poorly localized pain? Exaggerated pain
response to injury? Impaired function without a history of injury? Constitutional symptoms
(fever, night sweats, weight loss)? Incidental lesion on X-ray? Pathological fracture?
Asymptomatic &/or
Non-Active Bone Scan
Unicameral Bone Cysts
Aneurysmal Bone Cyst
Non-ossifying Fibroma
Symptomatic &/or
Active Bone Scan
Benign
No Bone Mineralization
Enchondroma (can calcify
&/or turn malignant)
Giant Cell Tumor (Soap
Bubble appearance)
Malignant
Bone mineralization, Constitutional
symptoms, Codman's Triangle,
Excessive scalloping & destruction
of cortical bone
Osteosarcoma (Codman's
Triangle)
Chondrosarcoma
(Popcorn appearance)
Ewing's Sarcoma
Inflammatory
Appearance
Osteoid Osteoma (Nidus
appearance)
Osteoblastoma (may be
malignant or sclerotic in
appearance)
Not Inflammatory
Appearance
Chondroblastoma
Chondromyxoid Fibroma
241
DEFORMITY/LIMP
Always check neurological and vascular status
one joint below the injury
Deformity/Limp
Infection
Septic Arthritis
Cortical
Hypertrophy
Osteomyelitis
Inflammation
Rheumatoid
Arthritis
Toxic Synovitis
Reactive Arthritis
Other Causes
Osteoarthritis
Osteomalacia
Rickets
Hip Joint
Hip Dysplasia
Slipped Capital
Femoral Epiphysis
Legg-Calve-
Perthes Disease
Knee Joint
Patellofemoral
Syndrome
(Chondromalacia
patellae)
Osgood-Schlatter
Disease
Patella (e.g.
Tendon Rupture,
Dislocation,
Subluxation)
Spine/Stature
Osteoporosis
Scoliosis/Spinal
Curvature
Dwarfism
242
ACUTE JOINT PAIN
Peri-Articular
Acute Joint Pain
Intra-Articular
Fibrous Cartilage
Meniscal Injury
Labral Injury
Slap Lesion
Ligament
Sprain
Dislocation (3
rd
Degree
Sprain)
Articular Cartilage/
Bone
Osteochondritis
dessicans
Bone Contusion
Fracture
Synovium
Traumatic Synovitis
one joint below the Injury
Skin/Fascia
Laceration
Contusion
Fat Pad Contusion
Ligament
Sprain
Dislocation (3
rd
Degree Sprain)
Tendon/Muscle
Tendon Rupture
Muscle Strain
Contusion
Bone
Fracture
Bursa
Aseptic Bursitis
243
CHRONIC JOINT PAIN
Bone
Stress Fracture
Charcot Joint
Articular Cartilage
Osteoarthritis
Chondromalacia
Joint Capsule
Baker Cyst
Ganglion Cyst
Adhesive Capsulitis
Chronic/Degenerative Change
Peri-Articular Intra-Articular
Bursa
Aseptic Bursitis
Epiphysis/
Apophysis
Slipped Epiphysis
Apophysitis
(Osgood-Schlatter
Disease)
Tendon
Enthesitis
Tendinopathy
Tendon Rupture
Impingement
Tenosynovitis
Ganglion Cyst
Bone
Stress Fracture
Charcot Joint
Pathologic
Fracture
Periostitis
Epicondylitis
Skin/Fascia
Fasciitis (e.g.
Myofascial Pain,
Iliotibial Band
Friction, Plantar
Fasciitis)
Muscle
Delayed Onset
Muscle Soreness
Fibromyalgia
Myositis
Ossificans
244
INFECTIOUS JOINT PAIN
Infectious Joint Pain
Polyarticular
Viral Myalgia
Viral Arthritis
Disseminated Gonococcal
Infection (Dermatitis, Migratory
Arthralgia & Tenosynovitis)
Secondary Syphilis (Red/Copper
Papules & Mucosal Lesions)
Fifth Disease (Erythema
Infectiosum & Symmetrical Rash)
Rubella (Measles-like Rash)
Primary HIV Infection
Monoarticular
Fever/Chills/Myalgia
Constant Pain
Increased Heat and Swelling
Signs & Symptoms of Viral Infection (e.g. Rhinitis/Cough)
Peri-Articular
Cellulitis
Necrotizing Fasciitis
Septic Bursitis
Abscess
Osteomyelitis
Lymphadenitis
Warts
Articular
Insidious Onset
Fungal Tuberculosis
Lyme Disease (Erythema
Migrans)
Acute Onset
Septic Arthritis
245
INFLAMMATORY JOINT PAIN
Monoarticular
Gout (Podagra, Tophi)
Pseudogout
Early Rheumatic Disease
Reactive (e.g. Genitourinary
Infection)
Oligoarticular (1-4 Joints)
Gout
Psoriatic (nail changes, Plaques)
Enteropathic (e.g. Inflammatory
Bowel Disease)
Reactive
Rheumatic Fever (recent
Pharyngitis, Carditis)
Lyme Disease (Tick bite, migratory
red Macules)
Polyarticular (>4 Joints)
Inflammatory Joint Pain
Peripheral Only Peripheral & Axial
Insidious Onset
Ankylosing
Spondylitis
Enteropathic (e.g.
Inflammatory Bowel
Disease)
Psoriatic
Insidious
Monoarticular
Symmetric
(Polymyositis/
Dermatomyositis)
Asymmetric
(Psoriatic Arthritis)
Migratory
Rheumatic Fever
Acute Onset
Reactive
Subacute &
Symmetrical
Rheumatoid
Arthritis
Systemic Lupus
Erythematosus
Sjgren's (aka.
Sicca) Syndrome
Scleroderma
Henoch-Schnlein
Purpura
Polymyalgia
Rheumatica
Wegener's
Granulomatosis
246
VASCULAR JOINT PAIN
Compression
Any structure
compressing the blood
vessels
Abscess
Cyst
Neoplasm
Dislocated Bone
Spasm
Vasculitis
Occlusion
Sickle Cell Anemia
Peripheral Vascular
Disease
Atherosclerosis
Deep Vein Thrombosis
Septic Embolism (e.g.
Infective Endocarditis)
Fat Embolism (e.g.
fractured long bone)
Air Embolism
Vasculitis
Disruption
Trauma to Vessel
(dislocation/fracture)
Hemarthrosis (Hemophilia
or Trauma)
Peripheral/Mycotic
Aneurysm (e.g. Marfan's
Syndrome, Infective
Endocarditis,
Atherosclerosis)
Vascular Joint Pain
Constant pain (Ischemia)
Acute onset
Increased pain with activity (Claudication)
Cold Extremity or Hyperemia
247
MYOTOMES: Segmental Innervation Of Muscles
Muscle Group Action Myotome Peripheral Nerve
Shoulder Abduction C5 Axillary Nerve
Adduction C6-C8 Thoracodorsal Nerve
Elbow Flexion C5 Musculocutaneous Nerve
Extension C7 Radial Nerve
Wrist Extension C6 Radial Nerve
Fingers Flexion C8 Median Nerve
Abduction T1 Ulnar Nerve
Hip Flexion L2 Nerve to Psoas
Extension S1 Inferior Gluteal Nerve
Abduction L5 Superior Gluteal Nerve
Knee Flexion L5 Tibial Nerve
Extension L3 Femoral Nerve
Ankle Dorsiflexion L4 Deep Peroneal Nerve
Plantarflexion S1 Tibial Nerve
N.B. There is considerable overlap between myotomes for some actions. The myotomes listed are the
dominant segments involved.
248
PATHOLOGIC FRACTURES
Toronto Notes for Medical Students, Inc. (2009).Toronto Notes 2009: Comprehensive Medical Reference and Review for MCCQE I & USMLE II.
McGraw-Hill: Toronto, Ontario.
Low Energy/No Exercise/Repeated Use
one joint below the injury
Osteomalacia/Ricketts
Diffuse Pain/
Proximal Muscle Weakness
Vitamin D Deficiency
Mineralization Defect
Phosphate Deficiency
Osteoporosis
Vertebrae/Hip/Distal Radius
Paget's Disease
Skull/Spine/Pelvis
Positive Alkaline Phosphatase
Renal Osteodystrophy
Secondary to Chronic Renal Failure
Pathologic/Fragility Fractures
Tumors
See Bone Lesions Scheme
Metabolic Bone
Disease
Post-menopausal
Elderly
Gastrointestinal Disease
Bone Marrow Disorder
Endocrinopathy
Malignancy
Drugs (e.g.
Corticosteroids)
Rheumatoid Disease
Renal Disease
Poor Nutrition
Immobilization
Primary Secondary
249
GUIDE TO SPINAL CORD INJURY
Spinal Sensory Motor Reflex
Root
C4 Acromioclavicular Joint Respiration None
C5 Radial Antecubital Fossa Elbow Flexion Biceps Reflex
C6 Dorsal Thumb Wrist Extension Brachioradialis Reflex
C7 Dorsal Middle Finger Elbow Extension Triceps Reflex
C8 Dorsal Little Finger Finger Flexion None
T1 Ulnar Antecubital Fossa Finger Abduction None
T7-12 See Dermatomes Abdominal Muscles Abdominal Reflex
L2 Anterior Medial Thigh Hip Flexion Cremasteric Reflex
L3 Medial Femoral Condyle Knee Extension None
L4 Medial Malleolus Ankle Dorsiflexion Knee Jerk Reflex
L5 Dorsal 3
rd
MTP Big Toe Extension Hamstring Reflex
S1 Lateral Calcaneus Ankle Plantarflexion Ankle Jerk Reflex
S2 Popliteal Fossa Anal Sphincter Bulbocavernosus
S3/S4 Perianal Region Anal Sphincter None
N.B. There is considerable variability in spinal cord levels for motor and reflex testing. Always test the level
above and below the suspected injury.
250
251
Psychiatric Presentations
Anxiety Disorders:
Associated with Panic 252
Anxiety Disorders:
Secondary to a Specific Stressor 253
Anxiety Disorders:
Recurrent Anxious Thoughts 254
Personality Disorders 255
Mood Disorders:
Past Depressive Episode 256
Mood Disorders:
With Psychotic Symptoms 257
Psychotic Disorders 258
Somatoform Disorders 259
Student Editors
Carmen Fong (Section Editor)
Kaitlin Chivers-Wilson
Leanne Foust
Faculty Editors
Dr. Aaron Mackie
Dr. Lara Nixon
252
ANXIETY DISORDERS: Associated with Panic
NB: If the symptoms are clinically significant but
do not meet the criteria for a specific anxiety
disorder, consider Anxiety Disorder Not
Otherwise Specified.
Anxiety, Fear, Avoidance
and/or Increased Arousal
Associated with Panic
and/or Physical
(autonomic) Symptoms
Associated with a Specific
Stressor
Associated with
Recurrent Anxious
Thoughts
Associated with Specific
Situation
Not Associated with
Specific Situation
Panic Disorder without
Agoraphobia
Avoidance of the Specific
Situation
Non-Avoidance of the
Specific Situation
Panic Disorder without
Agoraphobia
Specific Trigger
e.g. Flying, Heights, Animals etc.
Specific Phobia
Public Setting Where A
Negative Evaluation May
Occur
Social Phobia
Setting Where Patient May
Sense Difficulty in Escape
Panic Disorder With
Agoraphobia
1. Anxiety Review Panel, Evans M, Bradwejn J, Dunn L (Eds) (2000). Guidelines for the Treatment of Anxiety Disorders in Primary Care. Toronto: Queen's
Printer of Ontario, pp. 41.
2. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4
th
ed. DSM-IV-TR).
Rule out Anxiety Disorder due to General Medical
Condition or Substance-Induced Anxiety Disorder
253
ANXIETY DISORDERS: Secondary to a Specific Stressor
th
ed. DSM-IV-TR).
NB: If the symptoms are clinically significant but do
not meet the criteria for a specific anxiety disorder,
consider Anxiety Disorder Not Otherwise Specified.
and/or Physical
Stressor
Associated with
Recurrent Anxious
Thoughts
Medical Condition Traumatic Event
Substance (Medications,
Toxins, Drugs)
Substance-Induced Anxiety
Disorder
Anxiety Disorder Due to a
Medical Condition
Greater Than 1 Month
Post-Event
Post-Traumatic Stress
Disorder
Less Than 1 Month Post-
Event
Acute Stress Disorder
254
ANXIETY DISORDERS: Recurrent Anxious Thoughts
th
ed. DSM-IV-TR).
NB: If the symptoms are clinically significant but do
not meet the criteria for a specific anxiety disorder,
consider Anxiety Disorder Not Otherwise Specified.
and/or Physical
Stressor
Associated with
Recurrent Anxious
Thoughts
Excessive Worry/
Apprehension About
Common Concerns
Not Excessive Worry/
Apprehension About
Common Concerns
Excessive Worry/
Fear About Social
Situations
Social Phobia
Greater Than 6
Months
Generalized Anxiety
Disorder
Setting Where
Patient May Sense
Difficulty in
Escape
Agoraphobia without
History of Panic
Disorder
Thoughts are
Intrusive/
Inappropriate/
Distressing with
Repetitive
Behaviour Meant
to Neutralize
Anxiety
Obsessive
Compulsive
Disorder
Less Than 6
Months +
Stressors
Adjustment Disorder
with Anxiety
255
PERSONALITY DISORDERS
Enduring pattern of experience and behavior that deviates from the expectations of culture,
manifest in two or more of the following areas: cognition, affectivity, interpersonal functioning, and
impulse control. The pattern is inflexible and pervasive across many social and personal situations. The
pattern leads to distress or impairment in important areas of functioning. The pattern is stable and of long
duration, with an onset that can be traced back to adolescence or childhood. The pattern is not due to
another mental disorder or as a result of a substance or a medical condition.
Personality Disorder
Cluster C
(Anxious or Fearful)
Avoidant (Social inhibition, inadequacy)
Dependent (Psychological dependence
on others)
Obsessive-Compulsive (Rigid
conformity to rules, codes)
Cluster B
(Dramatic, Emotional, or Social)
Antisocial (Disregard for the law and
the rights of others)
Borderline (Instability of identity,
relationships and behavior)
Histrionic (Attention seeking,
exaggerated)
Narcissistic (Grandiosity, need for
admiration)
Cluster A
(Odd or Eccentric)
Paranoid (Irrational suspicion or
mistrust)
Schizoid (Lack of interest in social
relationships)
Schizotypal (Odd beliefs, perceptions,
and appearance)
256
MOOD DISORDERS: Past Depressive Episode
Depressed or Elevated Mood
Rule out Mood Disorder due to the physiologic effects of a General
Medical Condition or Substances (medications, toxins, drugs)
2 Weeks of Depressed Mood or Loss of
Interest Plus Associated Symptoms
Not Better Accounted for by Bereavement
Depressive Episodes in the Past
Greater Than 2 Weeks Ago
Numerous Periods with Hypomanic/
Depressive Symptoms for Over 2 Years
Numerous Periods with Hypomanic/
Depressive Symptoms for
Less Than 2 Years
Cyclothymic Disorder
Depressed Less Days Than Not
Depressed During Last 2 Years
Depressed More Days Than Not
Depressed During Last 2 Years
Dysthymic Disorder
In Response to a Major Stressor
Adjustment Disorder with Depressed Mood
Not Meeting Criteria for a
Specific Mood Disorder
Depressive Disorder Not Otherwise Specified
257
MOOD DISORDERS: With Psychotic Symptoms
Depressed or Elevated Mood
Rule out Mood Disorder due to the physiologic effects of a General
Medical Condition or Substances (medications, toxins, drugs)
2 Weeks of Depressed Mood or Loss of
Interest Plus Associated Symptoms**
Not Better Accounted for by Bereavement
Depressive Episodes in the Past
Greater Than 2 Weeks Ago
No Psychotic
Symptoms Present
Psychotic Symptoms
Present
Prior Manic or
Hypomanic Episode
Bipolar Disorder (Bipolar I
requires only the
presence of a manic
episode, whereas Bipolar
II requires both a major
depressive and a
hypomanic episode)
No Prior Manic or
Hypomanic Episode
Schizoaffective Disorder
(Bipolar or Depressive
Type)
Prior Manic or
Hypomanic Episode
No Prior Manic or
Hypomanic Episode
Major Depressive
Disorder
Psychotic Symptoms
Not Present At Times
Other Than During
Episode
Bipolar Disorder with
Psychotic Features
Psychotic Symptoms
Present At Times Other
Than During Episode
(Bipolar or Depressive
Type)
**Associated Symptoms
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicide
258
PSYCHOTIC DISORDERS
Psychotic Disorder
Psychosis (delusions and/or hallucinations and/or
disorganization of speech and/or disorganization of behavior)
Rule out Psychotic Disorder due to Substance Use or a General Medical Condition
Prominent mood syndrome (major
depression, mania) present for
significant portion of illness
Mood syndromes absent (or brief
relative to duration of psychotic
symptoms)
Psychotic symptoms
limited to non-bizarre
delusions only
Psychotic symptoms
present exclusively
during major mood
syndrome
Mood Disorder with
Psychotic Features
Psychotic symptoms
also present outside of
mood episodes
(Bipolar & Depressive)
Psychotic symptoms
not limited to delusions
Delusions
developed in the
context of close
relationship with
another person
who has already
established similar
delusion
Shared Psychotic
Disorder
Duration of illness
1-6 months
Schizophreniform
Disorder
Duration of illness
6 months
Schizophrenia
Non-bizarre
delusions in one
individual
Delusional Disorder
Duration of illness
5 1 month
Brief Psychotic
Disorder
259
SOMATOFORM DISORDERS
Patient presents with complex medical problem or
symptoms that cannot be explained medically
Somatoform Disorder
Symptoms Consciously
Produced
Symptoms Not Consciously
Produced
Focus is
appearance;
Exhibit significant
distress
Dysmorphic
Disorder
Motivation is
Secondary Gain
Malingering
Focus is the sick
role; not accepting
reassurance
Hypochondriasis
Focus is a
Physical Symptom
Motivation is
primary gain
(to assume the
sick role)
Factitious Disorder
Pain;
psychological
factors important
Pain Disorder
Multiple
symptoms;
long history
Somatization
Neurologic
Conversion Disorder
One or more
symptoms for at
least six months
Undifferentiated
Somatoform
Disorder
260
261
Otolaryngologic Presentations
Otalgia 262
Hearing Loss 263
Hoarseness: Etiology 264
Hoarseness: Laryngoscopy 265
Smell Dysfunction 266
Tinnitis: Subjective 267
Tinnitis: Objective 268
Student Editors
Joanna Debosz (Section Editor)
Dave Campbell
Faculty Editors
Dr. James Brookes
262
OTALGIA
Otalgia
No Pain With Outer Ear
Manipulation
Pain With Outer Ear
Manipulation
History of Jaw/Oropharyngeal
Problems
Temporomandibular Joint Injury
Neuralgia
Pharyngitis
Parotitis
Thyroiditis
Cervical Spine Injury
Cervical Adenitis
Canal
Otitis Externa
Malignant Otitis
Externa
Furunculosis
Auricle
Perichondritis
Erysipelas
Mastoid
Mastoiditis
Ulceration/
Abnormal Tissue
Growth
Squamous Cell
Carcinoma
Temporal Bone
Tumor
Other Malignancy
Benign Cysts
Bulging, Cloudy
Tympanic
Membrane
Otitis Media
263
HEARING LOSS
Hearing Loss
No Visible Obstruction
on Otoscopy
Sensorineural Loss Mixed Loss Conductive Loss
Symmetric
Confirm with Audiogram
Asymmetric
Perform MRI
Cerebello-
Pontine Angle
Tumor
Retrotrochlear
Tumor
Acoustic
Neuroma
Idiopathic
Unilateral
Sensorineural
Hearing Loss
Visible Obstruction
on Otoscopy
Cerumen
Foreign Body
External Ear Mass
Middle Ear Mass
Middle-Ear
Otitis Media
Cholesteatoma
Ossicular
Otosclerosis/
Fracture
Tumors (Glomus,
Adenoma)
Congenital
Membrane
Perforation
External Ear
Inflammation
Infection
Canal
Obstruction
Congenital
Trauma
Congenital
Hereditary
High Risk Birth
Retro-Cochlear
(Central)
Infection
(Meningitis)
Multiple
Sclerosis
Cardiovascular
Ischemia
Cochlear
(Inner Ear)
Presbycusis
Loud Noise/
Trauma
Infection
(Cochleitis)
Ototoxic Drugs
Inner Ear
Disease
(Mnire's,
Autoimmune)
264
HOARSENESS: Etiology
Hoarseness
Investigate etiologies for occupation & other causes
Wait for hoarseness to last > 3 months
Then refer to Hoarseness: Laryngoscopy Scheme
Neck Surgery
Recurrent
Laryngeal
Nerve
Paralysis
Prolonged
Intubation
Recurrent
Laryngeal
Nerve
Paralysis
Intubation
Granuloma
Neurologic
Disorders
(CVA, MS,
Parkinson's)
Recurrent
Laryngeal
Nerve
Paralysis
Tobacco Use
Polyp
Head & Neck
Cancer
Children/
Infants
Vocal Cord
Nodules
Mediastinal
Pathology (CV
Surgery)
Arnold-Chiari
Malformations
Papilloma
Occupation
(e.g. Teacher, Singer)
Voice Overuse
Other
Medications
Fungal
Viral
Gastro-
esophageal
Reflux Disease
265
Neoplastic
Leukoplakia
Laryngeal Cancer
Functional Infectious
Fungal
Structural
Polyps
Nodules
Polypoid Corditis
Hoarseness
HOARSENESS: Laryngoscopy
Laryngoscopy Results
Paralysis
Unilateral Muscle Tension
Dysphonia
Spasmodic Dysphonia
Laryngeal Conversion
Disorder
Hyperfunction
266
Smell Dysfunction
ENT history, physical exam, anterior rhinoscopy
Sensory testing to qualify and quantify the sensation
CT/MRI to rule out neoplasms, fractures,
congenital abnormalities
SMELL DYSFUNCTION
Toxins and Other
Factors
Toxin Exposure
Radiation
Drugs
Smoking
Trauma/Congenital
Foreign Body
Nasal Surgery
Head Trauma (Base
of skull fracture)
Choanal Atresia
Vestibular Stenosis
Kallman's Syndrome
Aging/
Psychogenic
Alzheimer's Disease
Parkinson's Disease
Multiple Sclerosis
Nasal Obstruction
and Upper
Respiratory
Infection
Nasal Polyps
Septal Deviation
Allergic Rhinitis
Bacterial/Viral
Infection
Intranasal or
Intracranial
Neoplasm
Endocrine/
Metabolic
AIDS
Alcoholism
Diabetes Mellitus
Adrenal
Hypofunction
Adrenal
Hyperfunction
Vitamin B12
Deficiency
Zinc Deficiency
Malnutrition
267
TINNITUS: Subjective
Subjective
Heard only by patient (Common)
Objective
Heard by others (Rare)
Tinnitus
Unilateral on Audiogram Bilateral on Audiogram
No Hearing Loss
Metabolic Causes:
Thyroid Dysfunction,
Vitamin A, B, Zinc
deficiency
Psychogenic,
Anxiety, Depression
Drugs (Caffeine,
salicylates,
quinidine,
indomethacin,
propranolol,
levodopa, loop
diuretics)
Idiopathic
Abnormal
Otoscopy
Impacted Cerumen
Foreign Body
Infection (Follow up
with MRI if not
resolved)
Head Trauma
Whiplash
Skull Fracture
Closed Head Injury
Hearing Loss
Normal Otoscopy
Perform MRI
Mnire's Disease
Acoustic Neuroma
Brainstem Lesion
Multiple Sclerosis
Infarction
Conductive
Hearing Loss
Negative Rinne &
Weber Tests
Lesion of External
or Middle Ear
Impacted Cerumen
Otitis Media
Otosclerosis
Sensorineural
Hearing Loss
Lesion of Cochlear
or Auditory Nerve
Noise-induced
Ototoxicity
Presbycusis
268
TINNITUS: Objective
Subjective
Heard only by patient (Common)
Objective
Heard by others (Rare)
Tinnitus
Pulsatile
Vascular
Continuous/Clicking
Muscular
Associated Carotid Bruit
Disappears with Pressure
on Jugular Vein
No Additional Findings
Atherosclerotic Vascular
Occlusion
Venous Hum
Hypertension
Hypothyroidism
Hyperthyoidism
High Jugular Bulb
Degenerative Disease of the
Head and Neck
Myoclonus of Stapedius or
Tensor Tympani Muscle
Patulous Eustachian Tube
Abnormal CT with Contrast &
MRI/MRA
Vascular Tumor
Arteriovascular Malformation
Developmental Anomaly
Normal CT with Contrast &
MRI/MRA
Blood flow in normal artery near
ear
269
Ophthalmologic Presentations
Pupillary Abnormalities: Isocoria 270
Pupillary Abnormalities: Anisocoria 271
Red Eye: Traumatic 272
Red Eye: Atraumatic 273
Amblyopia 274
Strabismus 275
Diplopia 276
Acute Vision Loss: Unilateral 277
Acute Vision Loss: Bilateral 278
Chronic Vision Loss: Anatomic 279
Student Editors
Stephanie Yang (Section Editor)
Vikram Lekhi
Anastasia Aristakhova
Faculty Editors
Dr. John Huang
Dr. Ying Lu
270
PUPILLARY ABNORMALITIES: Isocoria
Pupillary Abnormality
Equal (Isocoria) Unequal (Anisocoria)
Relative Afferent
Pupil Defect
Bilateral Impairment
Dilated Pupils Constricted Pupils
Syphilis
Diabetes Mellitus
Uveitis
Pharmacologic (e.g. Opioids,
Alcohol)
Dorsal Midbrain
(Perinaud's Syndrome)
Tumor
Hemorrhage
Hydrocephalus
Neuromuscular Junction
Dysfunction
Botulism
Pharmacologic
Atropine
LSD
Cocaine
Amphetamines
271
PUPILLARY ABNORMALITIES: Anisocoria
Pupillary Abnormality
Equal (Isocoria) Unequal (Anisocoria)
Physiological
Anisocoria equal in light and dark,
10% cocaine: pupils dilate symmetrically
Pathological
Simple Anisocoria (< 0.5 mm)
Impaired Dilation
Sympathetic dysfunction/Horner's
Syndrome: miosis, anhydrosis, ptosis.
Anisocoria greater in dark
(small pupil abnormality)
Local Iris Dysfunction
Impaired Constriction
Parasympathetic dysfunction:
Anisocoria greater in light
(large pupil abnormal)
Angle Closure Glaucoma
Iritis/Synechiae
Trauma
Postganglionic
Dilation with 0.125%
adrenaline
Cluster Headache
Carotid Dissection
Trauma
Idiopathic
Postganglionic
Constriction with 0.1%
pilocarpine
Tonic (Adie's) Pupil
(Ciliary Ganglion
Lesion)
Neuromuscular
Junction
No constriction with 0.1%
pilocarpine
Pharmacologic
Factitious
Preganglionic
No dilation with 0.125%
adrenaline
Idiopathic
Trauma
Tumor (Lung,
Breast, Thyroid)
Preganglionic
Ptosis, ophthalmoplegia,
constriction with 0.1%
pilocarpine
Oculomotor
Nerve/Fascicle
(Other Cranial
Nerve III Findings)
272
RED EYE: Traumatic
Red Eye
Traumatic Atraumatic
Associated Injury
Lids: swelling, laceration
Conjunctiva:
subconjunctival
hemorrhage
Cornea: abrasion
Iris: laceration, iritis,
iridodialysis
Pupil: traumatic mydriasis
Lens: cataract, dislocation
Vitreous hemorrhage
Retina: tear, hemorrhage,
choroidal rupture
Glaucoma
Optic Neuropathy
Surface Injury
Corneal Abrasion (Foreign
Body Sensation)
Ultraviolet Keratitis
Chemical (Acid, Alkali)
Blunt Trauma
Hyphema, diplopia, periorbital
ecchymosis, subcutaneous
emphysema of lid
Orbital Rim/Mid-facial
Fracture (Limited
horizontal movement)
Orbital Floor Fracture
(Limited vertical
movement,
endophthalmos,
infraorbital nerve
neuropraxia: cheek
anesthetized)
Optical Canal Fracture
Globe Penetrating
Injury
Hyphema, history of trauma/high
velocity impact, reduced visual
acuity
273
RED EYE: Atraumatic
Red Eye
Traumatic Atraumatic
Intraocular
Acute Angle
Closure
Glaucoma
(Severe pain,
nausea/vomiting,
decreased visual
acuity, fixed
dilated pupil,
increased intra-
ocular pressure)
Endophthalmitis
(Severe pain,
photophobia,
severely reduced
visual acuity, no
red reflex, ant
chamber cells/
flare)
Sclera
Episcleritis (Mild
pain,
rheumatologic
association,
blanches with
topical
phenylephrine)
Scleritis (Severe
pain,
photophobia, fails
to blanch with
topical
phenylephrine)
Cornea
Corneal Abrasion/
Erosion (Foreign
body sensation,
stains with
fluorescein, no
corneal infiltrate)
Keratitis/Corneal
Ulceration
(Foreign body
sensation,
photophobia,
stains with
fluorescein,
corneal infiltrate,
punctate
epithelial
spotting)
Uveal Tract
Iritis (Deep ache,
ciliary flush, ant
chamber cells/
flare)
Conjunctiva
Dry Eyes
(Burning, foreign
body sensation,
tearing)
Infectious
Conjunctivitis
(Viralwatery
discharge,
Bacterial
purulent
discharge,
chemosis)
Allergic
Conjunctivitis
(Itchy, watery
discharge,
chemosis)
Subconjunctival
Hemorrhage
(painless)
Lids/Orbit/
Lacrimal System
Blepharitis
(Erythema/
crusting of lid
margins, itchy,
associated with
stye & chalazion)
Dacrocysitis
(Swelling/pain
over lacrimal
duct, tearing)
Pre-septal
Cellulitis
(Erythema, skin
induration, normal
visual acuity,
pupils & extra-
ocular
movements)
Orbital Cellulitis
(Erythema, skin
induration, fever,
RAPD, reduced
visual acuity &
extra-ocular
movements)
274
AMBLYOPIA
Amblyopia
*Can cause permanent visual impairment if not treated urgently in infancy
Deprivational*
Obstruction of Visual Axis
Congenital Cataracts
Ptosis
Congenital Corneal Opacities
Vitreous Hemorrhage
Refractive Error
Anisometropia (Unequal
Refractive Error)
Hyperopia
Myopia
Astigmatism
Strabismic
Abnormal Binocular Interaction
See Strabismus scheme
275
STRABISMUS
Rule Out Amblyopia
Strabismus
Phoria
Misalignment when not working together,
latent deviation
Symmetrical corneal light reflex,
negative cover test, positive cover/uncover test
Tropia
Misalignment when working together,
manifest deviation
Asymmetrical corneal light reflex,
positive cover test
Esophoria (Eye moves medial to
straight when uncovered)
Exophoria (Eye moves lateral to
straight when uncovered)
Paretic
Non-comitant
Angle of misalignment changes in
different positions of gaze
Non-Paretic
Comitant
Angle of misalignment the same in
all positions of gaze
Accommodative Esotropia (Onset 2-4
years, Hyperopic)
Congenital Esotropia (Contralateral
eye moves medial when ipsilateral
covered)
Exotropia (Contralateral eye moves
lateral to straight when ipsilateral
covered)
Not Strictly Horizontal Strictly Horizontal
Cranial Nerve VI Problem (Eye cannot
abduct)
Cranial Nerve III Problem (Eye is
depressed and abducted, ptosis,
large/unreactive pupil)
Cranial Nerve IV Problem (Eye cannot
depress when looking medially)
276
DIPLOPIA
Diplopia
Monocular
Refractive Error
Cataract
Function
Keratoconus
Dislocated Lens
Binocular
Extraocular Muscle
Restriction/Entrapment
Orbital Inflammation
Orbital Tumor
Orbital Floor Fracture
Mononeuronal Junction
Myasthenia Gravis
Oculomotor Nerve
(Non-Comitant)
Strictly Horizontal
(Cranial Nerve VI problem)
Unable to abduct
Ischemia
Diabetes Mellitus
Aneurysm
Tumor
Trauma
Not Strictly
Horizontal
Grave's
Ophthalmopathy
Hyperthyroidism, dry eyes, lid
retraction, proptosis
Cranial Nerve III
Eye is depressed & abducted,
ptosis, large/unreactive pupil
Ischemia
Diabetes Mellitus
Aneurysm
Trauma
Cranial Nerve IV
Eye cannot depress when
looking medially
Ischemia
Diabetes Mellitus
Aneurysm
Trauma
Subdural Hemorrhage
277
Abnormalities of
Retina
Acute Vision Loss
ACUTE VISION LOSS: Unilateral
Bilateral Unilateral
Transient
Transient Ischemic Attack
Persistent
Abnormal Pupillary
Light Response
Normal Pupillary
Light Response
Functional Vision Loss
Retina Visible
on Fundoscopy
Retina Not Visible
on Fundoscopy
No Pain and
Conjunctival Injection
Corneal Ulcer
Severe Uveitis
Acute Angle Closure
Glaucoma
Endophthalmitis
Pain and
Conjunctival Injection
Vitreous Hemorrhage
Abnormalities of
Optic Nerve
(Neuropathy)
Temporal Arteritis
Demyelination
Multiple Sclerosis
Idiopathic
Glaucoma
Abnormalities of
Retina
Abnormalities of
Retina
(Vascular)
Retinal
Detachment/Tear
(Flashes &
Floaters)
Central Retinal
Artery Occlusion
Cilioretinal Artery
Occlusion
Peripheral Retinal
Artery Occlusion
278
ACUTE VISION LOSS: Bilateral
Acute Vision Loss
Bilateral Unilateral
Transient Persistent
Ocular Migraine
Transient Ischemic Attack
Abnormal Pupillary Light
Response
Normal Pupillary Light
Response
Symmetrical Field Loss
Drugs
Bilateral Simultaneous
Occurrence (i.e. Vascular)
Complete/Partial
Homonymous Hemianopsia
Optokinetic Nystagmus
Functional Vision Loss
No Optokinetic
Nystagmus
Occipital Lesions
279
CHRONIC VISION LOSS: Anatomic
Chronic Vision Loss
Perform slit-lamp exam to localize: Left Right on Scheme
Cornea
Keratoconus
Stromal Scaring
Neovascularization
Edema
Pterygium
Lens
Obscure Red Reflex,
Poor fundus visibility
Cataract
(Nuclear,
Subcapsular,
Cortical)
Macula
Drusen or Edema
Age Related
Macular
Degeneration
(Wet, Dry)
Retina
Cotton wool spots,
Micro-aneurysms,
Hemorrhage and
Macular Edema
Diabetic
Retinopathy
(Background,
Pre-
Proliferative,
Proliferative)
Optic Nerve
Pallor, Papilledema,
Irregular Disk,
Large Cup:Disk
Glaucoma
(Open-Angle)
Optic Tract
Visual field defects,
decrease in color vision
Optic Nerve
Compression
Pituitary Lesion
Meningioma
Craniopharyngioma
280
281
Pediatric Presentations
Developmental Delay 282
School Difficulties 283
Small for Gestational Age 284
Congenital Anomalies 286
Acute Abdominal Pain 287
Neonatal Jaundice 288
Pediatric Diarrhea 289
Failure to Thrive:
Adequate Calorie Consumption 290
Failure to Thrive:
Inadequate Calorie Consumption 291
Floppy Newborn 292
Depressed/Lethargic Newborn 293
Cyanosis in the Newborn:
Non-Respiratory 294
Cyanosis in the Newborn: Respiratory 295
Pediatric Dyspnea 296
Sudden Unexpected Death in Infancy 297
Enuresis 298
Acute Life Threatening Event 299
Student Editors
Cody Flexhaug (Section Editor)
Rebekah Jobling
Carmen Fong
Beata Komierowski
Shahbaz Syed
Carly Hagel
Gilbert Yuen
Faculty Editors
Dr. Pamela Veale
Dr. Susan Bannister
282
Dr. Kelly Millar
Dr. Mary Ann Thomas
Dr. Andrei Harabor
Dr. Jean Mah
Dr. Henry Mandin
Dr. Leanna Mckenzie
Dr. Ian Mitchell
Dr. Katherine Smart
283
DEVELOPMENTAL DELAY
Developmental Delay
Milestones Not Lost Milestones Lost
Neurodegenerative Disorder
Metabolic Disorder
Neoplastic Disorder
Vision and Hearing Normal Vision or Hearing Problem
Global Developmental
Delay
Syndromic
Genetic Disorder
Teratogenic Disorder
Isolated Domain Delay Diagnostic Grouping
Speech and Language
Developmental
Language Disorder
Motor
Cerebral Palsy
Primary Muscle Disorder
Language Delay and
Social Impairment
Autism Spectrum Disorder
Primary Motor and/or
Cognitive
Cerebral Palsy
Primary Muscle Disorder
284
SCHOOL DIFFICULTIES
School Difficulties
Primary Academic Difficulties Primary Medical Condition Primary Behavioral Difficulties
Inattentive/Hyperactive/
Impulsive Behavior
Attention Deficit
Hyperactivity Disorder
Defiant Behavior
Oppositional Defiant
Disorder
Conduct Disorder
Psychiatric Illness
Anxiety Disorder
Depressive Disorder
Home Environment
Neglect
Abuse
Trauma
Developmental Delay (See Developmental
Delay scheme)
Underlying Medical Disorder
Hearing or Vision Impairment
Learning Disorder (Specific academic
areas affected)
Cognitive Impairment (All academic areas
affected)
Attention Deficit Disorder
Social Skills Deficit
Autism Spectrum Disorder
No Social Skills Deficit
285
SMALL FOR GESTATIONAL AGE
Small For Gestational Age
Birth Weight < 10
th
Percentile
Fetal
Multiple Gestation
Intrauterine Infection (e.g.
TORCH Infections)
Chromosomal Anomaly
Syndromes
Placental
Placental Insufficiency
Maternal
Maternal Illness
Gestational Hypertension
HELLP Syndrome
Advanced Diabetes Mellitus
Malnutrition
Drugs
Alcohol
Narcotics
Cocaine
Other Substances
Social Factors
Low Socioeconomic Status
286
LARGE FOR GESTATIONAL AGE
Birth Weight > 90
th
Percentile
Maternal
Familial
Diabetes Mellitus (Macrosomia)
Fetal
Growth Acceleration
Selected Congenital Anomalies
287
CONGENITAL ANOMALIES
Congenital Anomalies
Deformation
Abnormal mechanical
forces distorting
otherwise normal
structures (e.g.
exoligohydramnios)
Malformation
Embryonic
development failure
or inadequacy (often
multifactorial)
Disruption
Destruction/
Breakdown of
previously normal
tissue (e.g. ischemia)
Isolated Multiple
Recognized
Association of
Anomalies
(Syndromic)
Chromosomal
Single Gene
Teratogenic
Association (e.g.
VACTERL)
Unrecognized
Pattern
Further workup
needed (eg.
Karyotype,
investigation for
other anomalies,
longitudinal follow-
up
History - Prenatal: maternal health, exposures, screening, ultrasounds; delivery; neonatal
Family History - Three Generation: prior malformations, stillbirths, recurrent miscarriages, consanguinity
Physical Exam - Variants, minor anomalies, major malformation
Diagnostic Procedures - Chromosomes, molecular/DNA, radiology, photography, metabolic
Diagnostic Implications - Prognosis, recurrence, prenatal diagnosis, surveillance, treatment
288
ACUTE ABDOMINAL PAIN
Acute Abdominal Pain
Evidence of Trauma - Rule Out Physical Abuse
Generalized
Intussusception
Gastroenteritis
Constipation
Diabetic Ketoacidosis
Intestinal Obstruction
Henoch-Schonlein Purpura
Congenital
Perforation
Focal
Lower Quadrant
Constipation
Inflammatory Bowel
Disease
Gastroenteritis
Ovarian Cyst
Ovarian Torsion
Pneumonia
Psoas Muscle
Abscess
Appendicitis
Mesenteric Adenitis
Suprapubic
Bladder Infection
Pelvic Inflammatory
Disease
Upper Quadrant
Cholecystitis
Liver Abscess
Pneumonia
Pyelonephritis
Splenic Injury
Epigastric
Gastritis
Peptic Ulcer
Pancreatitis
Gastroesophageal
Reflux Disease
289
NEONATAL JAUNDICE
Neonatal Jaundice
Pre-Hepatic
Unconjugated hyperbilirubinemia
Physiologic Pathologic
Hemolytic
Positive DAT
Negative DAT
Intrinsic Extrinsic
Post-Hepatic
Conjugated; diagnose by U/S
Biliary Atresia
Choledochal Cyst
Normal
Breast Milk
Jaundice
ABO Incompatibility
Rh Incompatibility
Spherocytosis
Elliptocytosis
G6PD Deficiency
Hemoglobinopathy
Infection
Arteriovenous
Malformation
Drugs
Determine if Hyperbilirubinemia is predominantly Conjugated or Unconjugated
Hepatic
Conjugated hyperbilirubinemia
Infection
1-Antitrypsin deficiency
Galactosemia
Hypothyroidism
Cystic Fibrosis
Drugs
Total Parenteral Nutrition
Idiopathic
Non-Hemolytic
Hematoma
Polycythemia
Sepsis
Hypothyroidism
Gilbert's Syndrome
Crigler-Najjar Syndrome
Dehydration
290
PEDIATRIC DIARRHEA
Diarrhea
Neonatal Older Child
Digestive
Milk Protein
Intolerance
Overfeeding
Necrotizing
Enterocolitis
'
Infectious
Gastroenteritis
Food Poisoning
Malabsorption
Lactase
Deficiency
Celiac Disease
Cystic Fibrosis
Primary
Immuno-
deficiency
Other
Drugs
Laxative Abuse
Inflammatory
Bowel Disease
291
FAILURE TO THRIVE: Adequate Calorie Consumption
Failure to Thrive
Adequate Calorie Consumption
Inadequate Calorie
Consumption
Psychosocial Illness
Neglect
Poverty
Oral Aversion
Disturbed Parent/Child Relationship
Organic Illness
Esophagitis
Congenital Heart Defect
292
FAILURE TO THRIVE: Inadequate Calorie Consumption
Failure to Thrive
Adequate Calorie Consumption
Inadequate Calorie
Consumption
Increased Losses
Vomiting
Gastroesophageal
Reflux
Renal Tubular Acidosis
Malabsorption
Pancreatic Insufficiency
(Cystic Fibrosis)
Celiac Disease
Liver Disease
Increased Demand
Chronic Respiratory
Disorder
Failure to Utilize
Metabolic
Syndromes
293
FLOPPY NEWBORN
Floppy Newborn
Upper Motor Neuron
(Central)
Lower Motor Neuron
(Peripheral)
Poliomyelitis
Guillain-Barre Syndrome
Botulism
Myasthenia Gravis
Myositis
Brain Lesion
Stroke
Tumor with increased Intracranial
Pressure
Todd's Paralysis
Meningitis/Encephalitis
Trauma
Toxic/Metabolic
Spinal Cord Lesion
Trauma
Hematoma
Abscess
Transverse Myelitis
Vasculitis
Arteriovenous Fistula
294
DEPRESSED/LETHARGIC NEWBORN
Depressed/Lethargic Newborn
Child Related Maternal Related
Drugs (e.g. SSRIs)
Diabetes Mellitus
Gestational Hypertension
Congenital
Birth Injury
TORCH Infections
Malformations
Respiratory
Respiratory Distress Syndrome
Pneumothorax
Birth Asphyxia
Meconium Aspiration
Sepsis
Other
Anemia
Shock
Hypothermia
Hypoglycemia
295
CYANOSIS IN THE NEWBORN: Non-Respiratory
Cyanosis
Central / Peripheral Peripheral Only
Poor Perfusion
Acrocyanosis
Cardiovascular Hemoglobinopathy
Congenital
Acquired
Sulfhemoglobin
Respiratory
Right-to-Left Shunt
Transposition of the Great
Arteries
Tetralogy of Fallot
Obstructive/Hypoplastic
Lesions
Aortic Atresia/Stenosis
Interruption of the Aortic
Arch
Aortic Coarctation
Left-to-Right Shunt
Patent Ductus Arteriosus
Ventricular Septal Defect
Atrioventricular Canal
Truncus Arteriosus
Common Atrium
Total Anomalous
Pulmonary Venous
Return
296
CYANOSIS IN THE NEWBORN: Respiratory
Cyanosis
Central / Peripheral Peripheral Only
Poor Perfusion
Acrocyanosis
Respiratory Hemoglobinopathy Cardiovascular
Reduced Respiratory
Drive
CNS Malformations
Seizures
CNS Hemorrhage
CNS Infections
Asphyxia
Metabolic Disease
Airway Obstruction
Atresia
Laryngomalacia
Tracheomalacia
Extrinsic Compression
Anatomic Obstruction
Lung Parenchyma
Immature Lung Disease
Pulmonary Edema
Pneumothorax
Malformation Infection
Aspiration
297
PEDIATRIC DYSPNEA
Dyspnea
Left-to-Right Shunt
Left Ventricular Failure
Tamponade
Neurological
Opiates
Increased Intracranial
Pressure
Neuromyopathies
Other
Diaphragmatic Hernia
Massive Ascites
Severe Scoliosis
Pleural
Pleural Effusion
Empyema
Pneumothorax
Upper Airway
Croup
Foreign Body
Aspiration
Laryngeal Edema
Laryngospasm
Epiglottis
Retropharyngeal
Abscess
Choanal Atresia
Lower Airway
Asthma
Bronchiolitis
Tracheitis
Bronchospasm
Parenchymal
Pneumonia
Atelectasis
Respiratory Distress
Syndrome
Vascular
Pulmonary Embolism
298
SUDDEN UNEXPECTED DEATH IN INFANCY
Sudden Unexpected Death in Infancy
Congenital Anomaly/
Disorder
Cardiac Anomaly
Cardiac Arrhythmia
Neurologic Anomaly
Pulmonary Anomaly
Infection
Severe Pneumonia
Sepsis
Gastrointestinal Infection
Injury
Deliberate
Accidental
Other
Acute Illness
299
ENURESIS
Rule in/out age-appropriate enuresis
as a significant proportion of children will
have urinary incontinence to a certain age.
Age Dry during day Dry during night
2 25% 10%
2.5 85% 48%
3 98% 78%
Enuresis
Nocturnal Enuresis
Primary
(Urinary Control Never Achieved)
Delayed Maturation (Familial)
Idiopathic
Sleep Disorders (Obstructive
Sleep Apnea)
Anatomic Abnormality
Secondary
(> 6 month Continence Prior)
Idiopathic
Behavioral/Psychogenic
Cystitis
Diabetes Mellitus
Other Acquired Conditions
(Diabetes Insipidus, Urethral
Obstruction, Neurogenic Bladder,
Seizure Disorder)
Diurnal Enuresis
Pediatric Unstable Bladder
Infrequent Voiding (Urinary Tract
Infection)
Cystitis
Behavioral/Psychogenic
Idiopathic
Non-Neurogenic Bladder
(Hinman Syndrome)
Vaginal Voiding (Labial Adhesion)
300
ACUTE LIFE THREATENING EVENT
Acute Life Threatening Event
Acute Illness Injury
Non-Accidental
Unnoticed
Factitious by Proxy
Apnea
Periodic Breathing
Apnea of Infancy
Cardiac
Congestive Heart
Disease
Arrhythmia
Cardiomyopathy
Myocarditis
Metabolic
Inborn Errors of
Metabolism
Reye's Syndrome
Electrolyte
Disturbances
Neurologic
Seizure
Malignancy
Structural
Neuromuscular
Disorders
Central Apnea
Respiratory
Anatomical
Foreign Body
Aspiration
Breath Holding
Spell
Infectious
Pneumonia
Sepsis
Upper
Respiratory Tract
Infection
Urinary Tract
Infection
Empyema
Gastrointestinal
Gastrointestinal
Reflux
Volvulus
Intussusception
Gastroenteritis
Incarcerated
Hernia
301
Other Presentations
Fever & Chills 302
Sore Throat/Rhinorrhea 303
Hypothermia 304
Fatigue 305
Student Editors
Kathy Truong (Section Editor)
Geoff Lampard
Faculty Editors
Dr. Harvey Rabin
Dr. Heather Baxter
Dr. Ian Wishart
302
FEVER & CHILLS
Acute Bacterial
Infection
High fever,
Severe malaise,
Rigors
Acute
Prolonged
(Fever of
Unknown Origin)
Septic Shock
Fever and Chills
Infection
Infective
Endocarditis
Tuberculosis
Uncommon
presentation of
common
infection
Neoplasm
Lymphoma
Collagen
Vascular
Disease
Systemic Lupus
Erythematosus
Rheumatoid
Arthritis
Other
Drug Fever
Factitious Fever
Inflammatory
Bowel Disease
Pancreatitis
Acute Viral
Infection
Moderate fever,
General malaise,
Congestion, Myalgia
Rhinovirus
Coronavirus
Influenza Virus
Adenovirus
Parainfluenza
Virus
Enterovirus
Superimposed
Bacterial Infection
Bacteremia
Transient
Bacteremia
Intermittent
Bacteremia
Continuous
Bacteremia
Acute Organ
Specific Infection
Upper Respiratory
Tract Infection
Urinary Tract
Infection
Pneumonia
Pyelonephritis
Meningitis
Skin Infection
Unknown Source
of Infection
Requires Empiric Therapy
Drug Fever
Factitious Fever
Inflammatory
Bowel Disease
Pancreatitis
303
SORE THROAT / RHINORRHEA
Sore Throat / Rhinorrhea
Predominantly Rhinorrhea Predominantly Sore Throat
Common viral pathogens:
Rhinovirus, Coronavirus, Influenza Virus, Parainfluenza Virus, Adenovirus, Herpes Simplex Virus,
Enterovirus (Coxsackie, Echo), Epstein Barr Virus, Cytomegalovirus, HIV
Most common bacterial pathogen:
Group A Beta Hemolytic Streptococcus pyogenes (GABHS)
Acute
Bacterial
Streptococcal
Tonsillopharyngitis
Peritonsillar Abscess
Ludwig's Angina
Viral
Acute Infectious
Mononucleosis
Acute Viral Pharyngitis
Acute Viral
Laryngotracheitis
Acute Viral
Tracheobronchitis
Acute Influenza
Herpangina
Acute
Acute Viral Sinusitis
Acute Bacterial Sinusitis
Acute Head Cold
Syndrome
Chronic
Allergic / Vasomotor /
Drug Rhinitis
Nasal Polyposis
Chronic Sinusitis
Nasopharyngeal Cancer
Chronic
Foreign Body
Neoplasm
Disease
Trauma
Environmental
304
HYPOTHERMIA
Other
Trauma
Sepsis
Vascular Insufficiency
Uremia
Body Heat Loss
Drugs/Toxins
Iatrogenic
Burns
Lack of Body Heat
Generation
Hypothyroidism
Hypoglycemia
Malnutrition
Improper
Thermoregulation
Drugs/Toxins
Cerebrovascular Accident
Central Nervous System
Trauma
Multiple Sclerosis
Hypothermia
Acute Illness Environmental
Immersion
Non-Immersion
305
FATIGUE
Infectious
Epstein-Barr
Virus
Hepatitis
Tuberculosis
Endocarditis
HIV
Chronic
Disease
Endocrine/
Metabolic
Organic Etiologies No Organic Etiologies
Fatigue
Exclude Sleep Disturbance/
Lifestyle Issues/Pregnancy
Neoplastic/
Hematologic
Anemia
Malignancy
Pharmacologic
Drug Abuse
(e.g. Alcohol)
Hypnotics
Anti-
depressants
Anti-
hypertensives
Drug
Withdrawal
Psychogenic
Depression
Anxiety
Eating Disorder
Somatization
Idiopathic
Chronic
Fatigue
Syndrome
Endocrine
Diabetes
Hypo/Hyper-
thyroidism
Adrenal
Insufficiency
Metabolic
Renal Failure
Liver Failure
Autoimmune/
Inflammatory
Rheumatoid
Arthritis
Celiac Disease
SLE
Polymyalgia
Rheumatica
Cardio-
pulmonary
Congestive
Heart Failure
Chronic
Obstructive
Pulmonary
Disease
Endocrine
Multiple
Sclerosis
Stroke
Parkinson's
Myasthenia
Gravis
306
307
Historical Executive Student Editors
2007 to 2008 Brett Poulin (Founder of the Calgary Black Book Project)
2008 to 2009 Linnea Duke
Mustafa Hirji
2009 to 2010 Lucas Gursky
Ting Li
2010 to 2011 Jonathan Dykeman
Kathy Truong
308
*If you are the author of a scheme currently used in the Calgary Black Book and believe you have not been credited appropriately, please
contact blackbk@ucalgary.ca*
List of Authors
Student Authors
M. Abouassaly
A. Aristarkhova
M. Broniewska
P. Chen
M. Chow
R. Cormack
P. Davis
L. Duke
J. Ebinu
A. Geist
F. Girgis
A. Hicks
J. Hodges
G. Ibrahim
C. Johannes
D. Joo
S. Khan
L. Kimmet
M. Klassen
J. Lawrence
J. Laxton
K. Leifso
V. Lekhi
S. Lipkewich
C. Lu
L. Luft
A. Lys
D. McDougall
B. McLane
S. McLean
J. McMann
J. Nadeau
B. Poulin
V. Prajapati
N. Ramji
K. Sahi
R. Schachar
P. Schneider
R. Simms
A. Skinn
U. Unligil
C. Verenka
H. Waymouth
P. Zareba
K. Zwicker
Faculty Authors
K. Burak
D. Burback
K. Busche
S. Casha
M. Clark
S. Coderre
M. Doran
P. Federico
K. Fraser
S. Furtado
N. Hagen
J. Huang
N. Jette
A. Jones
G. Klein
S. Kraft
A. Mahalingham
H. Mandin
J. Mannerfeldt
K. McLaughlin
L. Parsons
D. Patry
A. Peets
G. Pineo
M-C. Poon
H. Rabin
T. Remington
B. Ruether
A. Smithee
O. Suchowersky
P. Veale
B. Walley
L. Welikovitch
R.C. Woodman
L. Zanussi

-JTUPG"CCSFWJBUJPOT
AAA Abdomlnal Aortlc Aneurysm
ACL Anglotensln-Convertlng Lnzyme
ACTH Adrenocortlcotroplc Hormone
ADPKD Autosomal Domlnant Polycystlc
Kldney Dlsease
ADH Antldluretlc Hormone
A|N Acute |nterstltlal Nephrltls
ALS Amyotrophlc Lateral Sclerosls
AP8 Anglotensln Peceptor 8locker
APP Acute Penal Pallure
APPKD Autosomal Pecesslve Polycystlc
Kldney Dlsease
8PH 8enlgn Prostatlc Hypertrophy
CCD Cortlcal Collectlng Duct
CHP Congestlve Heart Pallure
C|N Chronlc |nterstltlal Nephrltls
CLL Chronlc Lymphocytlc Leukemla
CNS Central Nervous System
COPD Chronlc Obstructlve Pulmonary
Dlsease
CPP Chronlc Penal Pallure
CPH Cortlcotroplc Peleaslng Hormone
CT Computed Tomography
DC|S Ductal Carclnoma |n Sltu
DHLA Dehydroeplandrosterone
DHLA-S Dehydroeplandrosterone Sulfate
D|C Dlssemlnated |ntravascular
Coagulatlon
DKA Dlabetlc Ketoacldosls
DPL Dlgltal Pectal Lxam
DvT Deep veln Thrombosls
LA8v Lnectlve Arterlal 8lood volume
LCP Lxtracellular Pluld
LNaC Lplthellal Sodlum Channel
PLvl Porced Lxplratory volume ln One
Second
P1N Pamlllal 1uvenlle Nephronophthlsls
PSGS Pocal Segmental
Glomerulosclerosls
PSH Polllcle Stlmulatlng Hormone
PvC Porced vltal Capaclty
G8M Glomerular 8asement Membrane
GLPD Gastrolntestlnal Lsophageal Penux
Dlsease

GPP Glomerular Plltratlon Pate

GHPH Growth Hormone Peleaslng
Hormone
GH Growth Hormone
G| Gastrolntestlnal
GN Glomerulonephrltls
GnPH Gonadotropln Peleaslng Hormone
GPA Glucocortlcold-Pemedlable
Aldosteronlsm
GTN Gestatlonal Trophoblastlc
Neoplasm
H+ Hydrogen
HCG Human Chorlonlc Gonadatropln
HDL Hlgh Denslty Llpoproteln
HLLLP Hemolysls, Llevated Llver Lnzymes,
Low Platelets
H|v Human |mmunodeclency vlrus
HPL-la Human Perlpheral Lung Lplthellal
Cell Llne la
HPT Hormone Peplacement Therapy
HSP Henoch-Schnleln Purpura
HSv Herpes Slmplex vlrus
HUS Hemolytlc-Uremlc Syndrome
|8D |rrltable 8owel Dlsease
|8S |rrltable 8owel Syndrome
|CP |ncreased |ntracranlal Pressure
|CU |ntenslve Care Unlt
|GP |nsulln-llke Growth Pactor
|NP |nternatlonal Normallzed Patlo
|TP |dlopathlc Thrombocytopenlc
Purpura
|UGP |ntrauterlne Growth Pestrlctlon
|v |ntravenous
|vP |ntravenous Pyelogram
1vP 1ugular venous Pressure
K
+
Potasslum
KU8 Kldney, Ureter, 8ladder
LC|S Lobular Carclnoma |n Sltu
LDL Low Denslty Llpoproteln
LGA Large for Gestatlonal Age
LH Lutelnlzlng Hormone
LOC Level of Consclousness
LPL Llpoproteln Llpase
MCD Mlnlmal Change Dlsease
MCH Mean Corpuscular Hemoglobln
MCHC Mean Corpuscular Hemoglobln
Concentratlon
MCv Mean Corpuscular volume

MLN Multlple Lndocrlne Neoplasla

M| Myocardlal |nfarctlon
MPGN Membranoprollferatlve
Glomerulonephrltls
MS Multlple Sclerosls
MSK Musculoskeletal
Na
+
Sodlum
NSA|Ds Non-Sterlodal Antl-|nnammatorles
OCP Oral Contraceptlve Plll
OSM Osmolallty
PL Pulmonary Lmbollsm
P|D Pelvlc |nnammatory Dlsease
PMN Polymorphlc Neutrophlls
POSM Plasma Osmolallty
PPPOM Preterm Premature Pupture of
Membranes
PPOM Premature Pupture of Membranes
PT Prothrombln Tlme
PTH Parathyrold Hormone
PTT Partlal Thromboplastln Tlme
PUD Peptlc Ulcer Dlsease
PU1 Pelvlureterlc 1unctlon
PAPD Plght Anerent Puplllary Defect
PAS Penal Artery Stenosls
P8C Ped 8lood Cell
PTA Penal Tubular Acldosls
SGA Small for Gestatlonal Age
SLL Systemlc Lupus Lrythematosus
TOPCH Toxoplasmosls, Other (Hepatltls
8, Syphllls, varlcella-Zoster vlrus,
H|v, Parvovlrus 8l9), Pubella,
Cytomegalovlrus, Herpes Slmplex
vlrus
TSH Thyrold Stlmulatlng Hormone
TSHP Thyrold Stlmulatlng Hormone
Peceptor
TTKG Transtubular Potasslum Gradlent
TTP Thrombotlc Thrombocytopenlc
Purpura
UT| Urlnary Tract |nfectlon
US Ultrasound
vACTLPL vertebral Anomalles, Anal Atresla,
Cardlovascular Anomalles,
Tracheoesophageal Plstula,
Lsophageal Atresla, Penal
Anomalles, Llmb Anomalles
vSD ventrlcular Septal Defect
vU1 veslcoureteral 1unctlon
Approaching Medical Presentations with Schemes
Superficially resembling flowcharts, schemes are a way to ease
the memorization of differential diagnoses by breaking large lists
into sets of smaller, conceptually-intuitive information packets.
Using the Medical Council of Canadas Clinical Presentation
List, The Calgary Black Book organizes the most common
medical presentations of patients into diagnostic schemes. As a
tool for medical students, residents, allied health trainees, and
health care educators, medical presentation schemes will ease
the learning of the volume of medical diagnoses, and will
facilitate recall when needed.
Based on the medical presentation schemes used in the
University of Calgary Medical curriculum, The Calgary Black
Book is a joint production of the students and Faculty of
Medicine of the University of Calgary.
Copyright 2010. Faculty of Medicine, University of Calgary. All rights reserved.

CalgaryBlackBook 2013

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GPP Glomerular Plltratlon Pate

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