Diagnostic Checklists (L ast saved 2/1/2016 1:38 PM)€¦ · Diagnostic Checklists (L ast saved...

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Diagnostic Checklists (Last saved 2/1/2016 1:38 PM)

1. The purpose of these checklists is to prompt physicians toconsider a broad differential diagnosis for common symptomsin primary care and to help resist the most common cause ofmissing a diagnosis: failure to consider it. The lists are notexhaustive, but the goal is feasible because

a. It is possible to cover 99% of diagnostically challengingsymptoms with a short list, whereas 100% coverage wouldrequire a long list.

b. Similarly, for each symptom it is possible to cover 99%of the diseases that cause it with a short list.

c. Checklists are not needed for complaints that rarelypose diagnostic challenges, either because the list ofcauses is short (e.g., breast lump), the diagnosis isobvious (e.g., trauma, wart; but beware of multiple trauma,second fracture, etc.), there is a single cause thataccounts for the overwhelming majority of cases (e.g.,hypertension, obesity), the complaint prompts a standarddiagnostic approach which catches important diagnoseseven when not initially considered (e.g., rectal bleedingfollowed by colonoscopy), or the complaint is idiosyncratic(e.g., "funny feeling" in cheek).

d. The checklists may not include diagnoses that areexceedingly rare in North America or diagnoses in whichthe symptom is a late manifestation rather than apresenting complaint (e.g., abnormal uterine bleedingcaused by end-stage renal disease).

2. The diagnoses are listed in approximate order ofprevalence in primary care (most common diseases at the top).This ordering is based on limited published data and theauthors' experience. (National Ambulatory Medical CareSurvey:2010 Summary Tables.

Reprinted with Permission

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(http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf.) Accessed March 17,2015.)

3. Unless otherwise specified, the checklists primarily addressadults rather than children.

4. These checklists may have some advantages over moretraditional differential diagnoses:

a. A shorter list, practical at the point of care

b. Diseases ordered by prevalence in primary care

c. Identification of "must-not-miss" diagnoses,designated by an ace of spades (♠)

d. Identification of diagnoses that are commonlymissed, designated by an asterisk (*) and partlybased on Schiff GD, et al. Arch Intern Med.2009;169:1881-7; and on Zwaan L, et al. Arch InternMed. 2010 ;170:1015-21).

e. Lumping and splitting to meet the needs ofclinicians rather than pathologists or billers (e.g.,better to split "myocardial infarction" from "heartdisease," but better to lump "abnormal uterinebleeding" rather than splitting into "dysfunctionaluterine bleeding" vs. "structural causes" because thisdistinction may not be apparent initially).

5. The checklists are designed to be printed on 4x6 cards,two-sided, laminated, with a 3/4 inch metal binder ring in theleft upper corner. The lists could also be adapted for ahandheld computer.

The checklists are modified from Ely JW, Graber ML,Croskerry P. Checklists to reduce diagnostic errors. Acad Med.2011 Mar;86(3):307-13.


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Abdominal and pelvic pain (8/31/15)Dyspepsia (functional, ulcer, reflux)Viral gastroenteritisConstipationMedications (NSAIDs, iron)*Psychiatric (depression, sexual abuse)Irritable bowel syndromeAbdominal wall pain♠Gallbladder disease♠Pancreatitis♠Diverticulitis♠*Appendicitis♠Kidney stoneHerpes zosterMittelschmerz♠HerniaGastroparesis♠*Ectopic pregnancy, pregnancy complicationBacterial overgrowth♠*Myocardial infarctionCeliac diseaseFood poisoning♠*Diabetic ketoacidosis♠*Pneumonia, empyemaMesenteric lymphadenitis♠Hepatitis, hepatic abscess♠Bowel obstructionGiardiaEndometriosis, adenomyosis♠Ovarian cyst, ovarian torsion♠Pelvic inflammatory disease, endometritisLeiomyoma, degeneration, torsion, infarction♠*Intraabdominal tumor, lymphomaBladder distension, urinary tract infectionDysmenorrhea♠*Aortic dissection, ruptured aneurysm ♠ Don’t miss(Continued on next page) * Commonly missed

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Abdominal and pelvic pain (continued) (5/20/15)♠Mesenteric ischemia, infarction♠Subdiaphragmatic abscess♠Perforated viscus, peritonitisInflammatory bowel disease♠IntussusceptionCarbohydrate malabsorptionAcute pharyngitis♠Sickle cell crisis♠Lead poisoningSphincter of Oddi dysfunction♠Meckel's diverticulitisAbdominal migraine, abdominal epilepsyNarcotic bowel syndrome♠Fitz-Hugh-Curtis syndrome♠HypercalcemiaRadiculopathy (diabetes, cord tumor, tabes dorsalis)Periarteritis nodosa♠Hyper or HypothyroidismEosinophilic gastroenteritis♠LeukemiaEpiploic appendagitisSuperior mesenteric artery syndrome♠Spleen wandering, abscess, infarction , ruptureHereditary angioedemaCeliac artery compressionAdrenal insufficiencyFamilial Mediterranean FeverIliocostal friction syndrome♠*Abdominal compartment syndrome*Mesenteric panniculitisPorphyriaBudd-Chiari syndrome*ACE-inhibitor angioedemaHyperparathyroidism ♠ Don’t missBlack Widow Spider bite * Commonly missed

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Abnormal uterine bleeding (2/13/15)Anovulatory bleeding, polycystic ovary syndromeMenorrhagia (idiopathic)Contraceptive related abnormal bleeding (oral contraceptives,

depo-medroxyprogesterone, intrauterine device,progestin implant)

Normal variations (postmenarchal, perimenopausal,premenstrual spotting, postmenstrual spotting,midcycle ovulatory bleeding)

♠Ectopic pregnancy♠Intrauterine pregnancy complication♠Endometrial cancer, hyperplasiaUterine polypsUterine fibroidsAdenomyosis♠EndometritisHyperprolactinemiaThyroid diseaseDrugs (anticoagulants, psychotropics)Coagulopathy (von Willebrand disease)Organ failure (late manifestation: kidney failure, liver failure)

♠ Don’t miss* Commonly missed

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Annular skin lesions (10/5/15)Tinea corporisXerotic eczemaGranuloma annulareUrticariaErythema multiformePsoriasisPityriasis rosea (herald patch)Nummular eczemaSeborrheic dermatitisArthropod bitesAnnular and gyrate erythemasVasculitisHenoch-Schonlein purpuraLupus erythematosus (subacute cutaneous lupus)Annular lichen planus♠Erythema chronicum migrans (Lyme disease)♠Secondary syphilisCutaneous sarcoidosisAcute febrile neutrophilic dermatosis (Sweet Syndrome)Annular elastocytic giant cell granulomaSuperficial annulare centrifugumInterstitial granulomatous dermatitisId (autoeczematous) reactionsKawasaki’s diseaseEruptive xanthomasEruptive histiocytomas♠Erythema marginatum (Rheumatic fever)PorokeratosisLinear IgA bullous dermatosis♠Leprosy


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Anxiety, depression (6/19/15)♠Depression, agitated depression, bipolar disorderAnxiety (situational, generalized anxiety disorder)Panic disorderAlcohol♠HypoglycemiaMedications (caffeine, nicotine, pseudoephedrine)Medication or substance withdrawal (alcohol,

benzodiazepines)Illicit drugs (cocaine, amphetamines)Posttraumatic stress disorder♠Serotonin syndrome♠Thyroid disorderParaneoplastic syndrome♠Pulmonary embolus♠HypoxemiaAttention Deficit Hyperactivity Disorder♠Electrolyte imbalance♠Hypercalcemia, hyperparathyroidism♠*Delirium♠*Domestic abuseEhlers Danlos (Hypermobility syndrome)Postconcussion syndromeMultiple sclerosisRestless legs syndromeWilson disease♠Pheochromocytoma


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Arthralgias (7/9/15)Viremia (nonspecific, infectious mononucleosis, hepatitis,

cytomegalovirus, fifth disease, rubella, mumps,varicella, human immunodeficiency virus)

OsteoarthritisFibromyalgia Polyarteritis nodosaReactive arthritis Wegener’s granulomatosisPolyarticular gout AmyloidosisPseudogout ♠Rheumatic feverPolymyalgia rheumatica Familial Mediterranean FeverAnkylosing spondylitis Whipple’s diseasePsoriatic arthritisInflammatory bowel diseaseRheumatoid arthritis♠HypothyroidismLupus and drug-induced lupusSclerodermaEhlers Danlos (Hypermobility syndrome)Systemic vasculitisSystemic sclerosisPolymyositis/dermatomyositisStill’s diseaseBehcet syndromeDisseminated gonococcemiaRelapsing polychondritisAutoinflammatory disorders♠Adrenal insufficiency♠Lyme disease♠Bacterial endocarditisSarcoidosisPalindromic rheumatismHyperlipoproteinemias♠*Malignancy♠Septic joint ♠ Don’t missSickle cell disease * Commonly missed♠Compartment syndrome♠Acute myelopathy, radiculopathy, neuropathy

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Back pain (3/13/15)Musculoskeletal, osteoarthritis, degenerative disk diseaseHerniated diskSpinal stenosis♠Gall bladder diseaseCompression fracture♠PyelonephritisKidney stonePancreatitis,♠*Pulmonary embolus♠*PneumoniaPsychiatricHerpes zosterVitamin D deficiencyAnkylosing spondylitis (sacroiliitis)♠Polymyalgia rheumaticaProstatitis♠Cauda equina syndromeBack mousePancreatic carcinomaPiriformis syndromeAnkylosing spondylitis (sacroiliitis)Ehlers Danlos (Hypermobility syndrome)♠*Abdominal or thoracic aortic aneurysm♠*Metastatic tumor♠*Abdominal tumor♠Penetrating ulcer♠Infection (diskitis, osteomyelitis, spinal abscess)Iliocostal impingement syndromeRetroperitoneal fibrosis


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Back Pain in Children (3/13/15)Nonspecific musculoskeletalViral myalgiasScheuermann’s kyphosisSpondylolysis, spondylolisthesis♠Sickle cell crisisScoliosisPsychiatric♠PyelonephritisBack mouseHerniated disk♠Pneumonia♠Leukemia or lymphomaInflammatory spondyloarthropathies (ankylosing spondylitis,

inflammatory bowel disease, reactive arthritis)♠Trauma, vertebral fracture♠Sacroiliac joint infectionSyringomyeliaKidney stone♠Discitis♠Epidural abscess♠Vertebral osteomyelitisSlipped vertebral epiphysisJuvenile intervertebral disc calcification♠Tumor


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Breast pain (mastalgia) (9/4/11)Idiopathic mastalgiaCyclical (physiologic) breast painFibrocystic disease♠MastitisChest wall painLarge pendulous breasts (Cooper’s ligament stretching)Caffeine, nicotine♠PregnancyHormone replacement therapyDrugs (antibiotics, antidepressants, antipsychotics, estrogen,

progesterone, clomiphene, antihypertensives,metronidazole, ketoconazole, spironolactone)

Benign tumors♠Inflammatory breast cancerReferred painTraumaPsychiatricHerpes zosterThrombophlebitisMacrocystsDuctal ectasia♠Cancer♠Myocardial infarction♠Pulmonary embolusGastroesophageal reflux diseasePleurisy, pericarditisSickle cell diseaseHydradenitis supprativaPrior breast surgerySpinal disordersGall bladder diseaseHeart diseasePost thoracotomy syndrome


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Chest pain (9/15/15)Chest wall painGastroesophageal reflux diseasePleurisy, pleuritis*PsychiatricAsthma♠*Coronary disease (myocardial infarction, angina)♠*Pulmonary embolusHerpes zoster♠*Pneumonia, bronchitis♠PneumothoraxEsophageal spasmPericarditis, myocarditisMitral valve prolapseIdiopathic chest pain♠Acute chest syndrome (sickle cell anemia)♠Tuberculosis♠Aortic stenosis♠*Dissecting aortic aneurysm♠*TumorPulmonary hypertension♠Esophageal rupturePrecordial catch syndrome♠Mediastinitis♠*Spinal cord compression


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Cold feeling (8/7/12)IdiopathicAdvanced age, thin womanPsychiatric (anxiety)♠Hypothyroidism♠Shock♠SepsisRaynaud's phenomenonAnemiaWeight loss, malnutritionChronic illness♠Hypoglycemia


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Constipation (2/26/14)Functional (Idiopathic)Medications (anticholinergics. antidepressants, antipsychotics,

opiates, iron, calcium channel blockers)PregnancyDiabetic neuropathyDepressionHypokalemiaAnorexia nervosaHypothyroidismObstructionMultiple sclerosisSpinal cord injuryParkinson diseaseMyotonic dystrophySystemic sclerosisHirschprung disease


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Cough (4/10/13)Viral upper respiratory infectionPostnasal dripPostinfectious, postviral coughBronchitisAsthma, chronic obstructive pulmonary diseaseGastroesophageal reflux*Drugs (angiotensin converting enzyme inhibitors, beta

blockers, amiodarone)♠*PneumoniaExternal or middle ear diseaseAspiration, recurrent♠*Pulmonary embolus♠PertussisPsychogenic♠*Heart failure♠Human immunodeficiency virus♠*Lung tumor♠Epiglottitis♠Acute histoplasmosisInterstitial lung diseaseBronchiectasis♠Sarcoidosis♠*Tuberculosis♠Cystic fibrosis♠Laryngeal tumor♠Mitral stenosis♠Foreign body


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Cough, dyspnea (infant, newborn) (4/10/13)Viral upper respiratory infectionRespiratory syncytial virus (RSV)ParainfluenzaTransient tachypnea♠SepsisBronchiolitisInfant respiratory distress syndromeMetapneumovirusInfluenza♠Pertussis♠Pneumothorax♠PneumoniaAsthma♠Heart disease


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Crying infant (Inconsolable) (3/17/15)IdiopathicColic♠Infections (otitis media, viral illness, urinary tract infection,

herpes stomatitis, meningitis, osteomyelitis, septicjoint, thrush)

Neonatal abstinence syndrome (maternal drug use)♠FractureAnal fissureCorneal abrasionConstipationImmunization reaction♠Hair tourniquet syndrome (digits, penis)


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Delirium (4/8/15)♠*Drugs (opioids, hypnotics, antipsychotics, antihistamines)*Psychiatric disorders♠Alcohol♠*Anemia♠*Glucose disturbances♠Serotonin syndrome♠Trauma♠Head injury♠*Myocardial infarction♠Carbon monoxide♠SepsisSerious illness♠Electrolyte disturbance, Na, Ca, Mg, P♠Thyroid disease♠Hypoxia♠Neuroleptic malignant syndrome♠Hypertensive encephalopathy♠Central nervous system infections (neurosyphilis, human

immunodeficiency virus, herpes simplex)♠Brain mass♠Hypothermia♠Hyperthermia♠B12 deficiency♠Folate deficiency♠Thiamine deficiency♠Liver failure♠Stroke, intracranial hemorrhage♠*Heart failureFecal impaction, urinary retention♠Renal failureBurnsPostpartum psychosis♠Adrenal disease♠Porphyria ♠ Don’t miss♠Nonconvulsive status epilepticus * Commonly missed

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Dementia, memory loss (3/13/15)Alzheimer disease♠Pseudodementia (depression)Mild cognitive impairment♠Medications (antihistamines)Alcohol, Wernicke KorsakoffVascular dementiaFrontotemporal dementiaLewy body dementiaParkinson disease♠Vitamin B12 deficiency♠Hypothyroidism♠*Delirium♠Anoxia♠Hypoglycemia♠Head injury, subdural hematomaTransient global amnesia*Human immunodeficiency virus associated dementiaHuntington disease♠*Brain tumorProgressive supranuclear palsy♠Structural brain disease♠Hypercalcemia, hyperparathyroidismPrion disease (e.g., Creutzfeldt-Jacob)Dementia pugilisticaProgressive multifocal leukoencephalopathy♠Normal pressure hydrocephalus♠Niacin deficiencyCorticobasal degenerationParaneoplastic syndrome♠Whipple’s disease


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Depigmentation, hypopigmentation of skin (3/24/12)VitiligoTinea versicolorIdiopathic guttate hypomelanosisPostinflammatory hypopigmentationPityriasis albaHalo neviChemically induced (phenols)Nevus depigmentosusHypomelanosis of ItoPiebaldismMorpheaLeukodermaLichen sclerosisTuberous sclerosisAlbinism♠Leprosy


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Diarrhea (9/18/14)Viral gastroenteritisIrritable bowel syndrome*Drugs (antibiotics, caffeine, alcohol)SalmonellaShigellaE. coli O157 H7CampylobacterClostridium difficileFood poisoningLactose intolerance, fructose intoleranceBacterial overgrowth (e.g., diabetes, blind loop after surgery)DiabetesGiardiaMicroscopic colitisEntamoeba histolyticaCryptosporidiumInflammatory bowel diseaseCeliac diseaseYersiniaRadiation colitisIschemic colitisFecal impaction with leakageBypass operationsReduced bile salts (e.g., postcholecystectomy)Pancreatic insufficiency (pancreatitis, cystic fibrosis, cancer)Blastocystis hominisSclerodermaToxic shock syndrome♠*Human immunodeficiency virusLaxative abuseCystic fibrosis♠Whipple’s disease


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Dizziness, ill-defined (1/21/12)VasovagalBenign paroxysmal positional vertigoHyperventilation*Drugs (antihypertensives, antidepressants, gentamicin,

furosemide, alcohol, illicit drugs)Panic attack ♠Hypertrophic cardiomyopathyElderly multifactorial ♠Cardiac tamponadeOrthostatic hypotension Subclavian stealAutonomic insufficiency Atrial myxomaMeniere's disease ♠Multiple sclerosisVestibular neuronitis, acute labyrinthitisValsalva♠*AnemiaIdiopathic♠Arrhythmias♠HypoglycemiaPsychiatric♠Seizure, pseudoseizure♠GI bleeding♠Valvular heart disease, aortic stenosis♠*Pulmonary embolus♠*Myocardial infarction♠Hypoxia♠Aortic dissection♠Acoustic neuromaPost-concussion syndromeParkinson disease♠Otitis mediaBarotrauma, ruptured oval window, perilymph leakMigrainous vertigo♠Adrenal insufficiency, Addison's diseaseOtosclerosisCarotid hypersensitivity♠Vertebral artery dissection ♠ Don’t miss♠*Brain stem stroke * Commonly missedCough, micturition, defecation

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Dysphagia (2/4/14)Esophageal spasmLower esophageal ring (schatzke’s ring)Functional dysphagiaGlobus sensationEsophageal webPeptic strictureEsophageal diverticulum*drugs (anticholinergics, phenothiazines)Nutcracker esophagusZenker’s diverticulumSjogren’s syndromeAchalasia♠*Stroke♠*Tumor (intrinsic or extrinsic)Multiple sclerosisParkinson’s diseaseTardive dyskinesiaAmyloidosisCushing’s diseaseWilson’s diseaseAmyotrophic lateral sclerosisSclerodermaMyasthenia gravisGuillain-Barre’ syndrome


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Dyspnea, tachypnea (1/12/16)Asthma, chronic obstructive pulmonary diseaseFeverDeconditioning♠*PneumoniaPhysiologic dyspnea of pregnancyBronchitis*Psychiatric, hyperventilation, panic attack♠*Heart failure♠*Pulmonary embolus♠*Myocardial infarction♠Pneumothorax♠Cardiomyopathy♠Shock♠*Anemia♠*Tumor♠Pleural effusion♠Valvular heart disease♠Pulmonary hypertensionInterstitial fibrosis♠Metabolic acidosisDrugs (aspirin)Arrhythmias, atrial fibrillationAbdominal distension, obesity♠Cardiac tamponade♠Upper airway obstructionMyasthenia gravis♠Neuroleptic malignant syndrome♠Hyperthyroidism♠Foreign body aspiration♠Increased intracranial pressureWegener’s granulomatosis


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Ear pain, otalgia (8/26/10)Acute otitis media, otitis media with effusionTMJ syndrome Eagle's syndromeExternal otitis or external canal pustuleCerumenViral myringitisDental causesPharyngitisBarotraumaForeign bodyIdiopathicCervical adenopathyCellulitis, chondritis, perichondritis♠Acoustic neuroma♠*Myocardial infarction♠Nasopharyngeal tumor♠Temporal arteritis♠CholesteotomaSinusitisCarotidyniaTrauma♠MastoiditisGastroesophageal reflux♠Tumors (ear, nasopharyngeal)Bell's palsyWegener's granulomatosisCervical disc diseaseRamsey Hunt syndromeRelapsing polychondritis♠Malignant external otitis♠Coronary disease♠Thoracic aneurysm♠*Psychogenic (depression, anxiety)♠Thyroid tumorSalivary gland disorder ♠ Don’t missNeuralgias (trigeminal, glossopharyngeal)* Commonly missed

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Edema, leg (7/13/15)Venous insufficiency, dependency, garmentsObstructive sleep apnea (resulting in pulmonary hypertension)CellulitisStasis dermatitis*Drugs (NSAIDS, Ca channel blockers, steroids,

antidepressants, beta blockers, clonidine,estrogen/progesterone)

♠Deep vein thrombosis♠*Heart failureBaker's cyst ruptureRuptured gastrocnemiusComplex regional pain syndrome♠*Pelvic TumorIdiopathicHypoalbuminemiaCirrhosisLymphedemaMechanical edema (post injury or surgery)Renal failure, nephrotic syndromeHeart valve disease (pulmonic, tricuspid)♠Myxedema♠Constrictive pericarditisRetroperitoneal fibrosis


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Eye pain (5/19/15)ConjunctivitisCorneal abrasionForeign bodyStye (hordeolum)ChalazionBlepharitisScleritis, episcleritis♠Angle-closure GlaucomaMigraineEntropionMigraine or cluster headaches♠Ophthalmic zoster♠Intracranial massOptic neuritis (multiple sclerosis)♠Giant cell arteritisUveitis, iritisOptic neuritis


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Eyelid swelling (1/21/12)

BilateralContact dermatitisBlepharitisAtopic dermatitisRosaceaAngioedemaSystemic processes (myxedema, renal disease, congestive

heart failure, superior vena cava syndrome)♠Cavernous sinus thrombosis

Unilateral♠Orbital cellulitisHordeolum, styeChalazion♠Herpes simplex♠Herpes zoster ophthalmicusDacryocystitsTumors


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Facial flushing, hot flashes (4/8/15)EmotionalMenopauseAlcoholRosaceaDrugs (calcium-channel blockers, nicotinic acid, levodopa,

others)Heat exposureExercise♠FeverFoods (spicy foods, cured meats, monosodium glutamate)♠CarcinoidCluster headache♠Serotonin syndromeDumping syndrome♠Bronchogenic carcinoma♠Medullary thyroid carcinomaSarcoidosisHyperthyroidismSystemic mastocytosis♠Pheochromocytoma


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Facial pain (8/26/13)SinusitisDental painTemporomandibular joint syndromeTrigeminal neuralgiaHerpes zosterSalivary gland disordersMigraine♠Temporal arteritis♠GlaucomaPersistent idiopathic facial painDacryocystitis♠*Coronary disease♠*Aortic aneurysmRecurrent painful ophthalmoplegic neuropathyLung cancer


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Falls in the elderly (3/17/15)MultifactorialBalance disorderIdiopathicEnvironmental factors (new surroundings, walking surface

hazards)ArthritisMuscle weakness♠Acute illnessDrugs (sedatives, hypnotics, antidepressants,

antihypertensives)AlcoholPeripheral neuropathy (diabetes, B12 deficiency)Poor footwearConfusion, DementiaVestibular dysfunction♠Orthostatic hypotensionPostprandial hypotensionVitamin D deficiencyVisual disorder♠SyncopeParkinson disease


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Fatigue, malaise, vague symptoms (7/28/15)Obstructive sleep apnea♠Depression, anxiety LupusDeconditioning ♠*Delirium*Drugs (beta blocker, clonidine) ♠HypopituitarismChronic fatigue syndrome, fibromyalgia ♠Botulism♠*Infections (infectious mononucleosis, hepatitis, pneumonia,

mastitis, urosepsis, cytomegalovirus, tuberculosis,endocarditis, human immunodeficiency syndrome,Lyme, Coccidiomycosis, Giardia)

♠Pregnancy♠*Anemia Polyarteritis nodosaVitamin D deficiency Black widow spider bite♠Hypothyroidism, hyperthyroidism♠Hypokalemia, hyponatremia♠*Myocardial infarctionRestless legs syndrome♠Peripheral neuropathy (diabetes)♠Cancer, lymphoma♠Disturbance of calcium, phosphorus, magnesium♠Polymyalgia rheumatica/Temporal arteritisParkinson diseaseHypogonadism♠Celiac diseasePulmonary, hepatic, renal failurePulmonary hypertension*Ehlers Danlos syndrome♠*Heart failure, myocarditisMultiple sclerosis♠Carbon monoxideRheumatoid arthritis♠Adrenal insufficiency, Addison’s diseaseVitamin B12 deficiency♠Guillain-Barré syndromePost-Lyme disease syndromeMyasthenia gravis ♠ Don’t missWegener’s granulomatosis * Commonly missed

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Fever (acute, uncertain source) (7/9/15)♠Infections (pulmonary, gastrointestinal, urinary, sinusitis, skin,

*meningitis, bone, infectious mononucleosis, Lyme,cytomegalovirus, occult abscess, *humanImmunodeficiency virus, malaria, mastitis, West Nile,endocarditis, leptospirosis, tuberculosis, hepatitis)

♠Polymyalgia rheumatica♠*Malignancy, tumor lysis syndrome (lymphoma, leukemia,

renal cell, liver)♠*Myocardial infarction♠*Pulmonary embolus, deep vein thrombosisSurgical site inflammation (seroma, hematoma)♠Transfusion reaction♠Stroke, subarachnoid hemorrhage, intracranial hemorrhage♠Head trauma♠*Brain tumor♠Serotonin syndrome♠Necrotizing fasciitis♠Heat strokeGout♠Bowel ischemia, infarction♠HyperthyroidismConnective tissue disorder (autoimmune, lupus)PancreatitisToxic shock syndrome*Drugs (antibiotics, heparin, phenytoin)*Drug withdrawal (alcohol, opiates, barbiturates,

benzodiazepines)♠Malignant hyperthermiaSarcoidosisInflammatory bowel disease♠Neuroleptic malignant syndromePeriodic fever syndromes (PFAPA (periodic fever with

aphthous stomatitis, pharyngitis and adenitis) FamilialMediterranean Fever, others)

Factitious ♠ Don’t missWegener’s, polyarteritis nodosa * Commonly missed

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Flank pain (8/29/13)Musculoskeletal♠Kidney stone♠Pyelonephritis, renal abscess♠DiverticulitisHerpes zoster♠*PneumoniaInfluenzaPolycystic kidney disease♠*Ruptured aneurysmRenal infarctionRenal tumorPapillary necrosisSlipping rib syndromeIliocostal friction syndromeLoin pain hematuria syndrome


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Genital skin lesion, genital ulcer (3/17/15)Herpes simplexBehcet's disease♠CancerTraumaDrug reactions, fixed drug eruptionVestibulitisBartholin abscessLichen sclerosisLichen simplex chronicusPsoriasisLichen planus♠SyphilisChancroidLymphogranuloma venereumGranuloma inguinalePrimary Human immunodeficiency virusCytomegalovirusEpstein-Barr virus


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Groin pain (3/17/15)Groin muscle pullSports herniaHip arthritisLabral tearInguinal herniaHip stress fractureOsteitis pubisDistal abdominal rectus strainAdductor longus ruptureHip osteonecrosis (glucocorticoid use)Hip synovitisHip septic arthritis


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Hair Loss (3/17/15)Male pattern baldnessAndrogenetic alopecia (female pattern hair loss)Telogen effluvium (illness, pregnancy, weight loss)Alopecia areataTraction alopeciaMedications (anticoagulants, anticonvulsants, hormones, anti-

lipid agents, antihypertensives)Tinea capitisTrichotillomaniaIron deficiencyThyroid dysfunctionDiscoid lupusAnagen effluvium (chemotherapy, radiation)Loose anagen syndromeInherited disordersPrimary cicatricial (scarring) alopecias


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Headache (6/19/15)Daily withdrawal headachesMigraine Reversible cerebral vasoconstriction syndromeTension type headache VasculitisCaffeine withdrawal Pituitary apoplexy*Drug adverse effectSinusitisViral syndrome, febrile illnessTemporomandibular joint syndromeCervical arthritisSpinal headache (post lumbar puncture)♠Temporal arteritis♠*Subarachnoid hemorrhage♠Herpes ZosterOccipital neuralgia♠Carbon monoxide♠Acute severe hypertensionToxic exposuresPostconcussion syndromeIdiopathic thunderclap♠Preeclampsia♠Glaucoma♠*Meningitis/encephalitis/brain abscess♠Cerebral aneurysm♠*Domestic abuse♠Subdural hematomaNeuralgias (e.g., trigeminal neuralgia)Pseudotumor cerebri (intracranial hypertension)Cluster headache♠HSV encephalitis♠*Brain tumor♠*Stroke♠Human immunodeficiency virus♠Arterial dissections♠Cerebral venous sinus thrombosis ♠ Don’t missSpontaneous intracranial hypotension * Commonly missed

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Hearing loss (deafness) (3/17/15)PresbycusisCerumen♠Otitis media, otitis externaNoise exposure♠Acoustic neuromaMeniere's diseaseOtosclerosis♠Sudden sensorineural hearing lossViral cochleitis (herpes, influenza, mumps, others)♠Drugs (aspirin, gentamicin, furosemide, cisplatin)♠Stroke♠Hereditary, congenital hearing lossTrauma, barotrauma♠Cholesteatoma♠Meningitis♠NeoplasmAutoimmune hearing lossStroke, transient ischemic attackMultiple sclerosisDiabetes♠Lyme disease♠SyphilisSuperior semicircular canal dehiscence


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Hematuria (5/2/14)Transient unexplained hematuria♠Urinary tract infectionStonesMenstruation (contaminated urine)ExerciseTraumaBenign prostatic hypertrophyAtrophic vaginitis♠TumorProstatitisRadiation cystitisFactitious (finger stick)Glomerular disease (IgA nephropathy, hereditary nephritis,

postinfectious glomerulonephritis)HypercalciuriaPolycystic kidney diseaseUrethritisPapillary necrosis (nonsteroidal antiinflammatory drug overuse,

diabetes, sickle cell)Hyperuricosuria♠Renal infarctionInterstitial nephritisMedullary sponge kidney♠TuberculosisWegener’s granulomatosis♠Renal vein thrombus♠Malignant hypertension


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Hip pain (10/15/12)Hip osteoarthritisMuscle strain♠*Fracture (occult, pathologic, stress)TendinitisTrochanteric bursitisTransient synovitisLumbar disk diseaseMeralgia parestheticaOsteonecrosis, aseptic necrosis, avascular necrosisAortoiliac vascular occlusive diseaseSacroiliac joint diseaseAcute synovitis♠Septic arthritisMetastatic tumorPrimary bone tumorHerpes zoster♠OsteomyelitisLegg Perthes disease♠Slipped capital femoral epiphysisIdiopathic chondrolysis♠Psoas abscess♠LeukemiaSickle cell crisis


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Hypotension, shock (2/11/10)♠Hemorrhage (trauma, GI bleeding)HypovolemiaVomiting, diarrhea♠Pancreatitis*Drugs (e.g., antihypertensives)♠Cardiomyopathy♠*Myocardial infarction♠Aortic stenosis♠Arrhythmias♠Peritonitis♠Anaphylaxis♠*Pulmonary embolus♠*Ruptured aneurysm♠*Pneumothorax♠*Sepsis♠Aortic stenosis♠Hypertrophic cardiomyopathy♠Hypothyroidism♠Cardiac tamponade♠Addison's disease/Adrenal insufficiency/ hemorrhage♠Atrial myxoma


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Insomnia, sleep disturbance (1/23/12)Primary insomnia (psychophysiologic)DepressionAnxietyPoor sleep hygieneObstructive sleep apneaMedications, substances (caffeine, nicotine, pseudoephedrine,

cocaine, steroids, alcohol, others)Chronic lung diseaseMenopauseNocturia (diuretics, prostate hypertrophy, diabetes,

incontinence, heart failure)Environment (noise, temperature)Jet lagChronic pain♠*DeliriumRestless legs syndrome, nocturnal myoclonus


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Leg pain, bone pain, extremity pain (9/15/15)Arthritis♠*Fracture, trauma, stress fracture♠GoutVaricose veins♠CellulitisShin splintsTendinitis♠Deep vein thrombosisLumbar disc diseaseNeuropathy (e.g., diabetic)Meralgia parestheticaRuptured Baker's cystRuptured plantaris muscleVitamin D deficiency♠Compartment syndromeClaudication♠RhabdomyolysisEhlers Danlos (Hypermobility syndrome)Complex regional pain syndromeDiabetic amyotrophyChronic exertional compartment syndrome♠Osteomyelitis♠Arterial occlusionGastrocnemius tear♠Sickle cell crisis♠Bone tumor♠Leukemia


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Limp in child (8/7/15)Transient synovitis♠Fractures (toddlers, stress, foot, abuse)Soft tissue traumaGrowing painsChondromalacia patellaeOsgood-Schlatter's disease♠Slipped capital femoral epiphysisLegg-PerthesOsteochondritis dessicans♠Hip dysplasia♠TumorsConversion disorder♠Leukemia♠Septic arthritis♠Osteomyelitis♠DiskitisMuscular dystrophy


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Lymphadenopathy (1/20/10)Viral syndromeInfectious mononucleosisCat scratch disease♠Malignancy (lymphoma, leukemia, metastases)♠Human immunodeficiency virus♠*Tuberculosis, atypical mycobacteria♠TularemiaLupus♠Fungal infection (histoplasmosis, coccidiomycosis,

cryptococcis)Medications (phenytoin, serum sickness)♠Brucellosis♠Leptospirosis♠Syphilis♠Lyme diseaseSacoidosisAmyloidosisRubella


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Mental status, acute change (coma, lethargy) (1/25/12)♠*DeliriumAlcoholPsychosisDrug overdose♠Hypoglycemia♠*Intracranial hemorrhageSeizure (postictal)♠Urinary Retention♠Hypoxia♠CO2 narcosis♠*Pneumonia♠Head trauma♠Sepsis♠Meningitis, encephalitis♠Electrolyte abnormalityPsychiatric♠Hyperglycemic hyperosmolar state, diabetic ketoacidosis♠*Heart failure♠Status epilepticus♠Hypotension♠Brain stem stroke♠Disturbance of Ca, Mg, Na, K, P♠Thyroid disease (myxedema)♠Heat stroke♠Hypothermia♠Liver failure (hepatic encephalopathy)♠Renal failure (uremic encephalopathy)♠Brain tumor with herniation


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Mouth pain, burning mouth, burning tongue (2/3/11)Burning mouth syndrome (idiopathic)Psychiatric disordersAphthous stomatitisXerostomia (drugs, connective tissue disease, old age,

Sjogrens, radiation therapy, chemotherapy)♠Nutritional deficiencies (vitamin B12, iron, folate, zinc, vitamin

B6)Allergic contact stomatitisGeographic tongueCandidiasisDiabetesDenture-related painHerpes stomatitisThyroid abnormalitiesMenopauseLichen planus


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Mouth ulcers (1/25/12)Aphthous stomatitisHerpes simplexTraumaOral candidaHand, foot, and mouth diseaseHerpangina♠Primary Human Immunodeficiency Virus infectionDrug reactionBehcet's diseaseErythema multiformeStevens Johnson syndromeLichen planusChicken poxPemphigus, bullous pemphigoidReactive arthritis♠Squamous cell carcinomaNecrotizing ulcerative gingivostomatitis (Vincent’s

fusospirochetal disease)Inflammatory bowel disease♠Syphilis


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Muscle cramps (3/17/15)Idiopathic, ordinary, nocturnalPregnancyHeat-induced (volume depletion, hyponatremia)Exercise induced cramps*Medications (nifedipine, inhaled beta agonists, thiazides, beta

blockers, cisplatin, vincristine, oral contraceptives,others)

Hemodialysis (volume and electrolyte shifts)Lower motor neuron (injury, amyotrophic lateral sclerosis,

compression)Writer's crampDiabetesParkinson’s diseaseHypocalcemiaEhlers Danlos (hypermobility) syndromeHypomagnesemiaRespiratory alkalosisParkinson diseasePeripheral vascular diseaseHypokalemiaThyroid diseaseMcArdle's disease (glycogen storage disease)


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Myalgias, generalized (6/19/15)Viral syndrome, infectionsFibromyalgia♠*StatinsInfluenzaVitamin D deficiency♠Hypothyroidism♠Polymyalgia rheumatica♠RhabdomyolysisPolymyositis, dermatomyositis*Psychiatric♠*Domestic abuse♠Lyme diseaseEhlers Danlos (Hypermobility syndrome)♠Adrenal insufficiency♠*Human immunodeficiency virus♠HypophosphatemiaLupusRheumatoid arthritis


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Nausea, vomiting (5/20/15)Gastroenteritis, gastritis*Drugs (opioids, iron, chemotherapy)♠Pregnancy Cannabinoid hyperemesisMigraine ♠Diverticulitis♠*Appendicitis ♠Carbon monoxide♠Bowel obstruction ♠Addison's disease, adrenal insufficiencyGastroparesis (diabetes) ♠Serotonin syndromeEating disorder Cyclic vomiting syndrome♠Pyelonephritis Acute intermittent porphyriaIrritable bowel syndrome Parathyroid disordersVertigo Superior mesenteric artery syndromePeptic ulcer diseasePsychogenic vomiting, anxiety, depressionPain (especially visceral)Severe coughingPancreatitis♠Cholecystitis♠Brain tumorPseudotumor cerebri♠*Pancreatic carcinoma♠Hepatitis♠*Myocardial infarctionCrohn's disease♠Glaucoma♠*Human immunodeficiency virusMesenteric ischemia♠Lymphoma♠*Intracranial hemorrhage♠Intracranial abscess, meningitisInner ear (e.g., labyrinthitis, Meniere's)♠Uremia♠*Diabetic ketoacidosisLactose intoleranceFood poisoning♠Thyroid disorders ♠ Don’t miss xx♠*Congestive heart failure * Commonly missed

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Neck pain (1/25/12)Cervical sprainOsteoarthritisCervical lymphadenitisCervical disk diseaseShoulder pathologyCarotidyniaMigraineOccipital neuralgiaTorticollis♠Subarachnoid hemorrhagePsychiatricThyroiditisFibromyalgia♠Soft tissue space infections♠*Myocardial infarction♠TumorPericarditis♠Meningitis♠Ludwig's angina♠Dissecting aneurysm thoracic aorta♠Internal carotid artery dissection♠Vertebral artery dissection♠Transverse myelitis♠Cervical osteomyelitis


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Neck mass (6/23/14)Reactive viral lymphadenopathy (upper respiratory infection,

infectious mononucleosis, cytomegalovirus)Suppurative bacterial lymphadenopathy (strep throat, skin

infection)Thyroid noduleThyroglossal duct cystBenign skin cystLipomaCat scratch diseaseDermoid cystBranchial cleft cystLaryngoceleTumor, primary or metastatic, lymphomaHuman immunodeficiency virusTularemiaVascular tumors and malformationsMycobacteria (scrofula)Systemic disease (sarcoid, Sjögren, Kimura, Castleman,

Rosai-Dorfman)Lyme diseaseMumpsChancroidRat-bite feverBrucellosisLeptospirosisLymphogranuloma venereumTyphoid feverMeaslesRubellaHistoplasmosis, coccidioidomycosis, cryptococcosisToxoplasmosis, leishmaniasisSecondary syphilis


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Numbness, sensory loss, neuropathy (2/13/15)DiabetesIdiopathic peripheral neuropathyCompression neuropathyDisk diseaseCarpal tunnel syndromeMeralgia parestheticaHerpes Zoster♠*StrokeMultiple sclerosisAlcoholismPsychiatric, hyperventilation syndromeDrugs (vincristine, amiodarone, lithium, others)Monoclonal gammopathy♠Guillain-Barré syndrome♠Hypothyroidism♠Cauda equina syndrome♠Multiple myeloma♠Brain or cord tumorAmyloidosis♠*Human immunodeficiency virus♠Heavy metal poisoning (lead, mercury)Paraneoplastic syndrome♠HypocalcemiaChronic liver diseaseRenal insufficiency♠Lyme disease♠Vitamin B12, folate, B6 deficiencyHereditary neuropathies (e.g., Charcot-Marie-Tooth)Copper deficiencyPorphyria♠Leprosy (Hansen’s disease)


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Pruritus (12/16/13)Dry skin (xerosis)Atopic dermatitisContact dermatitisUrticariaBug bitesLichen simplex chronicusScabies, liceDiabetes*Drugs (narcotics, calcium channel blocker,

hydrochlorothiazide, angiotensin converting enzymeinhibitors, salicylates, chloroquine, allergic reaction,cholestasis, amphetamines, cocaine)

Pregnancy, third trimesterPhotodermatitisPsychiatric (delusional parasitosis)CholestasisLichen planusDermatitis herpetiformisRenal disease (uremia)Hepatitis C♠Human immunodeficiency virus♠Malignancy (Hodgkins lymphoma, polycythemia vera)♠Thyroid disease♠HyperparathyroidismNeuropathic pruritus (diabetic neuropathy, genital neural

impingement)*Iron deficiency anemiaBullous pemphigoid♠Mycosis fungoidesGrover disease


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Rash, generalized (2/13/15)Eczema, atopic♠*Drug reaction Erythema nodosumContact dermatitis Generalized granuloma annulareInsect bites ♠Toxic shock syndromeViral exanthem Swimmer’s itch, Seabather’s eruptionUrticaria ♠MeningococcemiaPoison ivy ♠Rocky Mountain Spotted FeverFolliculitis ♠Secondary syphilisSeborrheic dermatitis Disseminated varicella zosterTinea versicolor ♠MeaslesPsoriasis (plaque, pustular, erythroderm) ♠RubellaTinea corporis Sweet's syndromeGuttate psoriasis Grover’s diseaseCandida Acute generalized exanthematous pustulosisKeratosis pilaris DermatomyositisPityriasis rosea Darier’s diseaseLichen planus ♠Leprosy (Hansen’s disease)RoseolaScabiesNumular eczema♠Fifth Disease♠Lyme diseaseMiliaria rubra (prickly heat), miliaria crystallina♠Mycosis fungoides♠Erythema multiformeDermatitis herpetiformisId reaction♠Scarlet Fever♠Stevens-Johnson syndrome♠Kawasaki's diseaseUnilateral lateral thoracic syndromeChicken pox (Varicella)♠Human immunodeficiency virus acute exanthemLupus (subacute cutaneous)Disseminated bullous impetigo ♠ Don’t missEruptive xanthomas * Commonly missed

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Red eye (2/7/12)Viral conjunctivitisAllergic conjunctivitisStye (hordeolum)ChalazionBlepharitisDry eye syndrome (keratoconjunctivits sicca)Subconjunctival hemorrhageContact lens over wearEpiscleritis♠Foreign bodyCorneal abrasionTrauma♠Herpes zoster♠Chlamydia♠Bacterial conjunctivitis♠Scleritis♠Chemical burn♠Iritis (acute anterior uveitis)♠Keratitis, bacterial or viral♠Acute angle closure glaucoma♠HyperthyroidismCluster headache


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Red skin patch (8/20/14)CellulitisCandidaEczema, atopicNummular eczemaContact dermatitisBug bite reactionsImpetigoPsoriasisTineaPityriasis rosea herald patch♠Basal cell carcinomaDiscoid lupusFixed drug eruption♠Lyme disease♠Mycosis fungoides


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Rhinorrhea, nasal congestion (5/18/15)Viral upper respiratory infectionAllergic RhinitisVasomotor rhinitisSinusitisSeptal deviationRhinitis of pregnancyNasal polypsRhinitis medicamentosaAdenoid hypertrophyGustatory rhinitisForeign body♠Cerebrospinal fluid rhinorrheaNonallergic rhinitis with eosinophilia syndromeIntranasal cocaineMedications (estrogen, progesterone, aspirin, nonsteroidal

antiinflammatory drugs, clonidine, prazosin,doxazosin, beta blockers, calcium channel blockers,thiazides, angiotensin converting enzyme inhibitors,erectile dysfunction drugs, amitriptyline, risperidone,gabapentin)

Atrophic rhinitis♠Cystic fibrosis♠Nasal tumorsOvulatory rhinitis♠HypothyroidismWegener’s granulomatosis♠Midline granulomaSarcoidosis


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Scrotal pain (1/28/12)Idiopathic orchialgiaEpididymitisOrchitis (e.g., mumps, viral, bacterial)Post-vasectomy pain syndromeInguinal herniaUreteral stoneHydroceleVaricocele♠Testicular torsionAcute idiopathic scrotal edemaTorsion of appendix testis♠Fornier's gangrene♠Testicular cancerHenoch Schonlein purpura


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Seizure and seizure mimics (1/25/12)Febrile seizuresBreath holding spells (children)Imitators (vasovagal syncope, pseudoseizures (now called

psychogenic nonepileptic events), transient ischemicattack, arrhythmia, migraine)

Epilepsy (idiopathic)Alcohol and drug withdrawal (benzodiazepines)♠Head trauma♠Hypoglycemia♠HyponatremiaSandifer’s syndromeParasomniasTics♠Hypoxia♠*Stroke♠Brain tumor♠Meningitis, encephalitisVasculitis (systemic lupus erythematosus)♠Drug intoxication (cocaine, amphetamines)Uremia♠Hypomagnesemia♠Hypocalcemia


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Shoulder pain (5/13/14)Shoulder joint disease (rotator cuff tendinopathy, bicipital

tendinitis, labral tear, adhesive capsulitis,glenohumeral arthritis, acromioclavicular joint arthritis,labral tear)

Cervical radiculopathy (arthritis, disk, tumor)FibromyalgiaBiliary disease♠*Myocardial ischemia, infarction♠Intra-abdominal bleeding (ectopic, ruptured ovarian cyst)♠*Pneumonia♠Polymyalgia rheumaticaHerpes zosterBrachial plexitis/neuritis (Parsonage-Turner syndrome)♠*Lung tumor, Pancoast tumor♠*Pulmonary embolusPsychiatric♠Ruptured abdominal viscus♠Ruptured spleenAvascular necrosis humeral head♠Abdominal malignancyPericarditis


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Sinus tachycardia (6/22/15)Anxiety, emotional stressPainRecent physical exertionCOPD♠Infections, feverPregnancy (10 to 20 BPM at term)*Drugs (alcohol, amitriptyline, amphetamines, anticholinergics,

beta blocker withdrawal, bupropion, caffeine,cilostazol, cocaine, ephedrine, epinephrine,isoproterenol, nicotine)

Diabetic cardiovascular autonomic neuropathy♠*Myocardial infarction♠*Pulmonary embolus♠*Pneumonia♠*Anemia♠Hemorrhage♠Hypotension, shock♠Hypovolemia, dehydration♠Hyperthyroidism♠Hypoglycemia♠Heart failure, pulmonary edema♠Cardiomyopathy, myocarditis♠Pericarditis♠Acute mitral regurgitation♠Pneumothorax♠Aortic insufficiency♠Hypoxia♠Serotonin syndrome♠Neuroleptic malignant syndromeInappropriate sinus tachycardiaPostural orthostatic tachycardia syndrome (POTS)Chronic nonparoxysmal sinus tachycardia♠Pheochromocytoma


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Sore throat, pharyngitis (9/15/15)Viral pharyngitisAllergies♠Group A streptococciInfectious mononucleosisCytomegalovirusInfluenzaThrushUvulitisSmokingDry airReflux esophagitis♠Peritonsillar abscessMycoplasma♠AngioedemaHerpes simplexAcute thyroiditis♠Retropharyngeal space infection♠Submandibular space infectionArcanobacterium haemolyticum♠Primary human immunodeficiency virus♠Gonorrhea♠Epiglottitis♠*Repeated strangulation in domestic abuse♠Chlamydia pneumoniae♠Tularemia♠Lemierre syndrome (Fusobacterium necrophorum)♠Diphtheria



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Stroke and stroke mimics (8/26/15)♠Ischemic strokeMigraineBenign headacheBenign positional vertigo♠Intracerebral hemorrhage♠Subdural hemorrhage♠Subarachnoid hemorrhage♠Brain tumorTodd’s Palsy (following seizure)♠Hypoglycemia♠*Drug intoxicationSyncope♠Head traumaLabyrinthitisPeripheral neuropathyPsychiatric (conversion reaction)♠Systemic infection♠Central nervous system infectionMultiple sclerosis♠HyponatremiaHepatic encephalopathyGuillain Barre’Transient global amnesia♠Aortic dissectionAcute renal failure


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Sweating, excessive, hyperhidrosis, night sweats (1/25/12)Excess environmental heatIdiopathic, benignMenopausal hot flashesAnxiety*Drugs (antidepressants, triptans, antipyretics, tamoxifen,

raloxifene, alcohol, beta blockers, calcium channelblockers, omeprazole, opioids, tramadol, insulin,sulfonylureas, niacin, sildenafil)

♠HyperthyroidismGastroesophageal reflux disease♠Tuberculosis♠Human Immunodeficiency Virus♠Endocarditis♠Bacterial infections♠Hepatitis C♠Carcinoid♠Hypoglycemia♠*Malignancy (lymphoma, solid tumors)♠*StrokeAutonomic dysreflexiaAutonomic neuropathyFood additivesValley Fever (Coccidiomycosis)MastocytosisSpinal cord injury♠Pheochromocytoma


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Syncope, near syncope (7/13/15)Vasovagal (emotion, pain, fear, prolonged standing, heat,

exertion, cough, micturition, no trigger)Orthostatic hypotensionHyperventilation*Drugs, alcoholPanic attackAutonomic insufficiencyValsalva♠*Anemia♠Arrhythmias♠Hypoglycemia♠Seizure, pseudoseizure♠GI bleeding♠Valvular heart disease, aortic stenosis♠*Pulmonary embolus♠*Myocardial infarction♠Hypoxia♠Aortic dissection♠Adrenal insufficiency, Addison's disease♠Long QT syndrome♠Brugada syndrome♠Hypertrophic cardiomyopathyPulmonary hypertension♠Carotid sinus sensitivity♠Cardiac tamponade♠*Cerebrovascular (TIA, stroke)♠Atrial myxoma


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Tinnitus (3/17/15)IdiopathicPresbycusisNoise-induced hearing lossMeniere’s diseaseDrugs (aspirin, antibiotics, loop diuretics, chemotherapy)Temporomandibular joint disorder♠Acoustic neuromaCongenital hearing lossCochlear trauma, barotrauma♠Vascular, pulsatile (arteriovenous malformation, bruit, fistula)StrokeOtosclerosisMultiple sclerosisPatulous eustachian tubeVestibular schwannoma♠Glomus tumor


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Tremor (1/25/12)Physiologic tremorEssential tremor, familial tremorAnxietyParkinson’s disease♠Hyperthyroidism♠Tardive dyskinesiaMedications (bronchodilators, caffeine, steroids, lithium,

sympathomimetics, antipsychotics, metoclopramide,tricyclics, valproic acid)

Drug withdrawal (alcohol)Psychogenic tremorOrthostatic tremor♠Cerebellar disease♠Midbrain strokeMultiple sclerosis♠Serotonin syndrome♠CarcinoidHepatic encephalopathy♠Wilson's disease♠Pheochromocytoma


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Urinary symptoms (dysuria, frequency, urgency) (4/8/15)♠Urinary tract infection♠Urethritis (chlamydia, gonococcus, unknown)VaginitisAtrophic vaginitisGenital herpesInterstitial cystitis (painful bladder syndrome)Overactive bladderIdiopathic urgency incontinenceIrritant urethritisDaytime frequency of childhood syndrome♠ProstatitisReactive arthritis (Reiter's syndrome)HypercalciuriaPsychiatric♠Appendicitis♠Diverticulitis


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Vertigo (1/25/12)Benign paroxysmal positional vertigoMeniere's diseaseVestibular neuronitis, acute labyrinthitis♠Acoustic neuromaPost-concussion syndrome♠Otitis mediaBarotrauma, ruptured oval window, perilymph leakMigrainous vertigoOtosclerosis♠Vertebral artery dissectionMultiple sclerosis♠*Brain stem strokePsychiatric♠Drugs (gentamicin, furosemide, phenytoin, aminoglycosides,

diazepam, aspirin, alcohol)


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Weakness (objective muscle weakness) 7/28/15Cachexia♠StrokeDisuse atrophy♠Hypokalemia♠RhabdomyolysisDrugs (cocaine, heroin, alcohol, corticosteroids, colchicine,

antimalarial drugs, statins)♠HyponatremiaCompression neuropathy (e.g., Saturday night palsy)Multiple sclerosisMyasthenia gravisMuscular dystrophyPeripheral neuropathyPolymyositisDermatomyositis♠HypothyroidismCushing’s syndromeAmyotrophic lateral sclerosisInclusion body myositis♠Hypophosphatemia♠HypocalcemiaViral infections♠Lyme myositis♠Trichinosis♠Toxoplasmosis


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Weight loss (7/9/15)♠DepressionChronic obstructive pulmonary disease*DrugsDementia♠*Malignancy, lymphomaEating disorderAnorexia of aging*Diabetes♠Hyperthyroidism♠*Human immunodeficiency virus♠*Tuberculosis♠Adrenal insufficiency♠UremiaLiver disease, hepatitisHeart failureAlcoholIllicit drugsSocial factors (isolation, no money)Voluntary (exercise)Intestinal parasites♠Celiac diseaseMalabsorptionSwallowing disordersValley fever (Coccidiomycosis)Lupus♠HypopituitarismInflammatory bowel diseaseWegener’s granulomatosisPolyarteritis nodosa♠Whipple’s disease


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Prepared by:John W. Ely, MD, MSPH;Professor Emeritus,

University of Iowa Carver College of Medicine

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