Abdominal Distention

Abdominal Pain, Adolescence ²⁷

• Other: functional abdominal pain, pelvic inflammatory disease, pregnancy, pyelonephritis, renal stone, trauma, anxiety

Abdominal Pain, Childhood ²⁷

• Acute gastroenteritis

• Appendicitis

• Constipation

• Anxiety

• Cholecystitis, acute

• Intestinal obstruction

• Pancreatitis

• Neoplasm

• Inflammatory bowel disease (IBD)

• Other: functional abdominal pain, pyelonephritis, pneumonia, diabetic ketoacidosis (DKA), heavy metal poisoning, sickle cell crisis, trauma

Abdominal Pain, Chronic Lower ³⁹

FUNCTIONAL DISORDERS

Common

• Irritable bowel syndrome

• Functional abdominal bloating

Uncommon

• Functional abdominal pain

Abdominal Pain, Diffuse

• Early appendicitis

• Aortic aneurysm

• Gastroenteritis

• Intestinal obstruction

• Diverticulitis

• Peritonitis

• Mesenteric insufficiency or infarction

• Pancreatitis

• Inflammatory bowel disease (IBD)

• Irritable bowel

• Mesenteric adenitis

• Metabolic: toxins, lead poisoning, uremia, drug overdose, diabetic ketoacidosis (DKA), heavy metal poisoning

• Sickle cell crisis

• Pneumonia (rare)

• Trauma

• Urinary tract infection, pelvic inflammatory disease (PID)

• Other: acute intermittent porphyria, tabes dorsalis, periarteritis nodosa, Henoch-Schönlein purpura, adrenal insufficiency

Abdominal Pain, Epigastric

• Gastric: peptic ulcer disease (PUD), gastric outlet obstruction, gastric ulcer

• Duodenal: PUD, duodenitis

• Biliary: cholecystitis, cholangitis

• Hepatic: hepatitis

• Pancreatic: pancreatitis

• Intestinal: high small bowel obstruction, early appendicitis

• Cardiac: angina, myocardial infarction (MI), pericarditis

• Pulmonary: pneumonia, pleurisy, pneumothorax

• Subphrenic abscess

• Vascular: dissecting aneurysm, mesenteric ischemia

• Other: gastroenteritis, anxiety

Abdominal Pain, Infancy ²⁷

• Acute gastroenteritis

• Appendicitis

• Intussusception

• Volvulus

• Meckel’s diverticulum

• Other: colic, trauma

Abdominal Pain, Left Lower Quadrant

• Intestinal: diverticulitis, intestinal obstruction, perforated ulcer, inflammatory bowel disease (IBD), perforated descending colon, inguinal hernia, neoplasm, appendicitis, adhesions

• Reproductive: ectopic pregnancy, ovarian cyst, torsion of ovarian cyst, tubo-ovarian abscess, mittelschmerz, endometriosis, seminal vesiculitis

• Renal: renal or ureteral calculi, pyelonephritis, neoplasm

• Vascular: leaking aortic aneurysm

• Psoas abscess

• Trauma

Abdominal Pain, Left Upper Quadrant

• Gastric: peptic ulcer disease (PUD), gastritis, pyloric stenosis, hiatal hernia

• Pancreatic: pancreatitis, neoplasm, stone in pancreatic duct or ampulla

• Cardiac: myocardial infarction (MI), angina pectoris

• Splenic: splenomegaly, ruptured spleen, splenic abscess, splenic infarction

• Renal: calculi, pyelonephritis, neoplasm

• Pulmonary: pneumonia, empyema, pulmonary infarction

• Vascular: ruptured aortic aneurysm

• Cutaneous: herpes zoster

• Trauma

• Intestinal: high fecal impaction, perforated colon, diverticulitis

Abdominal Pain, Nonsurgical Causes

• Irritable bowel syndrome

• Urinary tract infection, pyelonephritis, salpingitis, pelvic inflammatory disease (PID)

• Gastroenteritis, gastritis, peptic ulcer

• Diverticular spasm

• Hepatitis, mononucleosis

• Pancreatitis

• Inferior wall myocardial infarction

• Basilar pneumonia, pulmonary embolism

• Diabetic ketoacidosis (DKA)

• Strain or hematoma of rectus muscle

• Ruptured graafian follicle

• Herpes zoster

• Nerve root compression

• Sickle cell crisis

• Acute adrenal insufficiency

• Other: acute porphyria, familial Mediterranean fever, tabes dorsalis

Abdominal Pain, Periumbilical

• Intestinal: small bowel obstruction or gangrene, early appendicitis

• Vascular: mesenteric thrombosis, dissecting aortic aneurysm

• Pancreatic: pancreatitis

• Metabolic: uremia, diabetic ketoacidosis (DKA)

• Trauma

• Irritable bowel, anxiety

Abdominal Pain, Poorly Localized ²⁷

EXTRA-ABDOMINAL

• Metabolic: diabetic ketoacidosis (DKA), acute intermittent porphyria, hyperthyroidism, hypothyroidism, hypercalcemia, hypokalemia, uremia, hyperlipidemia, hyperparathyroidism

• Hematologic: sickle cell crisis, leukemia or lymphoma, Henoch-Schönlein purpura

• Infectious: infectious mononucleosis, Rocky Mountain spotted fever, acquired immunodeficiency syndrome (AIDS), streptococcal pharyngitis (in children), herpes zoster

• Drugs and toxins: heavy metal poisoning, black widow spider bites, withdrawal syndromes, mushroom ingestion

• Referred pain:

• Pulmonary: pneumonia, pulmonary embolism, pneumothorax

• Cardiac: angina, myocardial infarction, pericarditis, myocarditis

• Genitourinary: prostatitis, epididymitis, orchitis, testicular torsion

• Musculoskeletal: rectus sheath hematoma

• Somatization disorder, malingering, hypochondriasis, Munchausen’s syndrome, functional

INTRA-ABDOMINAL

• Early appendicitis, gastroenteritis, peritonitis, pancreatitis, abdominal aortic aneurysm, mesenteric insufficiency or infarction, intestinal obstruction, volvulus, ulcerative colitis

Abdominal Pain, Pregnancy ²⁷

NONGYNECOLOGIC

• Appendicitis (throughout)

• Cholecystitis (throughout)

• Hepatitis (throughout)

• Pyelonephritis (throughout)

• Preeclampsia (>20 wk)

Abdominal Pain, Right Lower Quadrant

• Intestinal: acute appendicitis, regional enteritis, incarcerated hernia, cecal diverticulitis, intestinal obstruction, perforated ulcer, perforated cecum, Meckel’s diverticulitis

• Reproductive: ectopic pregnancy, ovarian cyst, torsion of ovarian cyst, salpingitis, tubo-ovarian abscess, mittelschmerz, endometriosis, seminal vesiculitis

• Renal: renal and ureteral calculi, neoplasms, pyelonephritis

• Vascular: leaking aortic aneurysm

• Psoas abscess

• Trauma

• Cholecystitis

Abdominal Pain, Right Upper Quadrant

• Biliary: calculi, infection, inflammation, neoplasm

• Hepatic: hepatitis, abscess, hepatic congestion, neoplasm, trauma

• Gastric: peptic ulcer disease (PUD), pyloric stenosis, neoplasm, alcoholic gastritis, hiatal hernia

• Pancreatic: pancreatitis, neoplasm, stone in pancreatic duct or ampulla

• Renal: calculi, infection, inflammation, neoplasm, rupture of kidney

• Pulmonary: pneumonia, pulmonary infarction, right-sided pleurisy

• Intestinal: retrocecal appendicitis, intestinal obstruction, high fecal impaction, diverticulitis

• Cardiac: myocardial ischemia (particularly involving the inferior wall), pericarditis

• Cutaneous: herpes zoster

• Trauma

• Fitz-Hugh–Curtis syndrome (perihepatitis)

Abdominal Pain, Suprapubic

• Intestinal: colon obstruction or gangrene, diverticulitis, appendicitis

• Reproductive system: ectopic pregnancy, mittelschmerz, torsion of ovarian cyst, pelvic inflammatory disease (PID), salpingitis, endometriosis, rupture of endometrioma

• Cystitis, rupture of urinary bladder

Abdominal Wall Masses ³⁹

LUMPS ARISING IN THE SKIN AND SUBCUTANEOUS FAT (THAT COULD OCCUR ANYWHERE ON THE BODY)

• Lipoma

• Sebaceous cyst

LUMPS ARISING IN THE SKIN AND SUBCUTANEOUS FAT (SPECIFIC TO THE ANTERIOR ABDOMINAL WALL)

• Tumor nodule of the umbilicus (secondary to intraperitoneal malignant neoplasm, also called Sister Mary Joseph nodule)

LUMPS ARISING IN THE FASCIA AND MUSCLE

• Rectus sheath hematoma (usually painful)

• Desmoid tumor (associated with Gardner’s syndrome)

HERNIA

• Incisional: It has an overlying scar. The sac may be very much larger than the neck of the hernia.

• Umbilical: The hernia is through the umbilical scar. Those presenting at birth commonly resolve in the first years of life.

• Paraumbilical: The neck is just lateral to the umbilical scar. Patients usually present later in life.

• Epigastric: It occurs in the midline between the xiphoid process and the umbilicus. They are usually small (<2 cm). They result when a knuckle of extraperitoneal fat extrudes through a small defect in the linea alba. Commonly irreducible and without an expansile cough impulse.

• Spigelian: A rare hernia found along the linea semilunaris at the lateral edge of the rectus sheath, most commonly a third of the way between the umbilicus and the pubis.

DIVARICATION OF THE RECTI

• Supraumbilical elliptical swelling of attenuated linea alba (no cough impulse)

Abortion, Recurrent

• Congenital anatomic abnormalities

• Adhesions (uterine synechiae)

• Uterine fibroids

• Endometriosis

• Endocrine abnormalities (luteal phase insufficiency, hypothyroidism, uncontrolled diabetes mellitus [DM])

• Parental chromosome abnormalities

• Maternal infections (cervical Mycoplasma, Ureaplasma, Chlamydia infection)

• Diethylstilbestrol (DES) exposure, heavy metal exposure

• Thrombocytosis

• Allogenic immunity, autoimmunity, lupus anticoagulant

Abruptio Placentae

• Placenta previa

• Cervical or vaginal trauma

• Labor

• Cervical cancer

• Rupture of membranes

Abscess, Brain

• Other parameningeal infections: subdural empyema, epidural abscess, thrombophlebitis of the major dural venous sinuses and cortical veins

• Embolic strokes in patients with bacterial endocarditis

• Mycotic aneurysms with leakage

• Viral encephalitis (usually resulting from herpes simplex)

• Acute hemorrhagic leukoencephalitis

• Parasitic infections: toxoplasmosis, echinococcosis, cysticercosis

• Metastatic or primary brain tumors

• Cerebral infarction

• Central nervous system (CNS) vasculitis

• Chronic subdural hematoma

Abscess, Breast

• Sebaceous cyst with infection

• Inflammatory carcinoma

• Advanced carcinoma with erythema, edema, or ulceration

• Hidradenitis of breast skin

• Tuberculous abscess (rare)

Abscess, Liver

Abscess, Lung

• Bacterial (anaerobic, aerobic, infected bulla, empyema, actinomycosis, tuberculosis)

• Fungal (histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis, cryptococcosis)

• Parasitic (amebiasis, echinococcosis)

• Malignant neoplasm (primary lung carcinoma, metastatic lung disease, lymphoma, Hodgkin’s disease)

• Wegener’s granulomatosis, sarcoidosis, endocarditis, septic pulmonary emboli

Abscess, Pelvic

• Pelvic neoplasms, such as ovarian tumors and leiomyomas

• Inflammatory masses involving adjacent bowel or omentum, such as ruptured appendicitis or diverticulitis

• Pelvic hematomas, as may occur after cesarean section or hysterectomy

Abscess, Perirectal

• Pilonidal disease

• Crohn’s disease (inflammatory bowel disease [IBD])

• Hidradenitis suppurativa

• Tuberculosis or actinomycosis; Chagas’ disease

• Cancerous lesions

• Chronic anal fistula

• Rectovaginal fistula

• Proctitis—often STD associated—including syphilis, gonococcal, chlamydial, chancroid, condylomata acuminata

• AIDS associated: Kaposi’s sarcoma, lymphoma, cytomegalovirus (CMV)

• Neutropenic enterocolitis

Abuse, Child

In all categories, accidental injury is the most common entity to be distinguished from abuse. Accidental injuries are most common over bone prominences: forehead, elbows, knees, shins; soft, fleshy areas are more common for inflicted injury: buttocks, thighs, upper arms.

BRUISING

• Bleeding disorder (idiopathic thrombocytopenic purpura, hemophilia, leukemia, hemorrhagic disease of the newborn, von Willebrand disease)

• Connective tissue disorder (Ehlers-Danlos syndrome, vasculitis)

• Pigments (mongolian spots)

• Dermatitis (phytophotodermatitis, nickel allergy)

• Folk treatment (coining, cupping)

BURNS

• Chemical burn

• Impetigo

• Folk treatment (moxibustion)

• Dermatitis (phytophotodermatitis)

INTRACRANIAL HEMORRHAGE

• Bleeding disorder

• Perinatal trauma (should resolve by 4 wk)

• Arteriovenous malformation rupture

• Glutaric aciduria

FRACTURES

• Osteogenesis imperfecta

• Rickets

• Congenital syphilis

• Very low birth weight (osteopenia of prematurity)

SEXUAL ABUSE

• Normal variants

• Lichen sclerosus et atrophicus

• Congenital abnormalities

• Urethral prolapse

• Hemangioma

• Non–sexually acquired infection (group A streptococcus, Shigella)

Abuse, Elder

• Advancing dementia

• Depression or other psychiatric disorder

• Malnutrition from intrinsic causes

• Conscious nonadherence

• Financial hardship

• Falling

Acanthosis Nigricans

• Seborrheic keratosis

• Hyperpigmented nevus (Becker’s nevus), linear epidermal nevus

• Pemphigus vegetans

• Lichen simplex chronicus

• Confluent and reticulated papillomatosis

Achalasia

• Peptic ulcer disease

• Postvagotomy dysmotility

• Esophageal disease: gastroesophageal reflux disease (GERD), sarcoidosis, amyloidosis, esophageal stricture, esophageal webs and rings, scleroderma, Barrett’s esophagus, Chagas’ disease, esophagitis

• Diffuse esophageal spasm

• Malignant neoplasm: esophageal cancer, infiltrating gastric cancer, lung cancer, lymphoma

• Gastric bezoar

Aches and Pains, Diffuse ²⁵

• Postviral arthralgias/myalgias

• Bilateral soft tissue rheumatism

• Overuse syndromes

• Fibrositis

• Hypothyroidism

• Metabolic bone disease

• Paraneoplastic syndrome

• Myopathy (polymyositis, dermatomyositis)

• Rheumatoid arthritis (RA)

• Sjögren’s syndrome

• Polymyalgia rheumatica

• Hypermobility

• Benign arthralgias/myalgias

• Chronic fatigue syndrome

• Hypophosphatemia

Achilles Tendon Rupture

• Incomplete (partial) tendo Achillis rupture

• Partial rupture of gastrocnemius muscle, often medial head (previously thought to be “plantaris tendon rupture”)

Acidosis, Lactic

TISSUE HYPOXIA

• Shock (hypovolemic, cardiogenic, endotoxic)

• Respiratory failure (asphyxia)

• Severe congestive heart failure (CHF)

• Severe anemia

• Carbon monoxide (CO) or cyanide poisoning

SECONDARY TO DRUGS OR TOXINS

• Salicylates

• Ethanol, methanol, ethylene glycol

• Fructose or sorbitol

• Biguanides (phenformin, metformin [usually occurring in patients with renal insufficiency])

• Isoniazid

• Streptozocin

• Nucleoside reverse transcriptase inhibitors (e.g., zidovudine, didanosine, stavudine)

HEREDITARY DISORDERS

• Glucose-6-phosphate dehydrogenase (G6PD) deficiency and others

Acidosis, Metabolic

METABOLIC ACIDOSIS WITH INCREASED ANION GAP (ANION GAP ACIDOSIS)

• Lactic acidosis

• Ketoacidosis (diabetes mellitus [DM], alcoholic ketoacidosis)

• Uremia (chronic renal failure)

• Ingestion of toxins (paraldehyde, methanol, salicylate, ethylene glycol)

• High-fat diet (mild acidosis)

Acidosis, Respiratory

• Pulmonary disease (chronic obstructive pulmonary disease [COPD], severe pneumonia, pulmonary edema, interstitial fibrosis)

• Airway obstruction (foreign body, severe bronchospasm, laryngospasm)

• Thoracic cage disorders (pneumothorax, flail chest, kyphoscoliosis)

• Defects in muscles of respiration (myasthenia gravis, hypokalemia, muscular dystrophy)

• Defects in peripheral nervous system (amyotrophic lateral sclerosis, poliomyelitis, Guillain-Barré syndrome, botulism, tetanus, organophosphate poisoning, spinal cord injury)

• Depression of respiratory center (anesthesia, narcotics, sedatives, vertebral artery embolism or thrombosis, increased intracranial pressure)

• Failure of mechanical ventilator

Acne Keloidalis

• Folliculitis

• Simple ingrowing hairs (pili incarnati)

• Nevus sebaceus

• Traumatic causes of keloid

• Acne vulgaris

• Pseudofolliculitis

• Pediculosis capitis

Acne Vulgaris

• Gram-negative folliculitis

• Staphylococcal pyoderma

• Acne rosacea

• Drug eruption

• Sebaceous hyperplasia

• Angiofibromas, basal cell carcinomas, osteoma cutis

• Occupational exposures to oils or grease

• Steroid acne

• Flat warts

Acoustic Neuroma

• Benign positional vertigo

• Meniere’s disease

• Trigeminal neuralgia

• Cerebellar disease

• Normal-pressure hydrocephalus

• Presbycusis

• Glomus tumors

• Vertebrobasilar insufficiency

• Ototoxicity from medications

• Other tumors: meningioma, glioma, facial nerve schwannoma, cavernous hemangioma, metastatic tumors

Acquired Immunodeficiency Syndrome (AIDS)

• Other wasting illnesses mimicking the nonspecific features of AIDS

• TB

• Neoplasms

• Disseminated fungal infection

• Malabsorption syndromes

• Depression

• Other disorders associated with dementia or demyelination producing encephalopathy, myelopathy, or neuropathy

Acrochordon

• Wart

• Seborrheic keratosis

• Melanocytic nevus

• Dermatosis papulosa nigra

• Neurofibroma

• Melanoma

Acromegaly

• Pituitary neoplasm

• Ectopic production of growth hormone–releasing hormone (GHRH) from carcinoid, other neuroendocrine tumor

Actinic Keratosis

• Heavily pigmented variants may be clinically mistaken for lentigo maligna.

• Basal cell or squamous cell carcinoma

• Seborrheic keratosis

• Eczema

• Bowen’s disease (intraepithelial carcinoma)

• Wart

• Lichenoid keratosis

• Cutaneous lupus

Actinomycosis

• Nocardiosis

• Botryomycosis

• Chromomycosis

• Intestinal tuberculosis

• Ameboma

• Crohn’s disease

• Colon cancer

• Other causes of acute, subacute, or chronic infections of the lung, abdomen, hepatic, gastrointestinal (GI), genitourinary (GU), musculoskeletal, and CNS systems

Acute Bronchitis

• Cough secondary to medications

• Neoplasm (elderly patients)

• Influenza

• Allergic aspergillosis

• Gastroesophageal reflux disease (GERD)

• Congestive heart failure (CHF) (in elderly patients)

• Bronchogenic neoplasm

Acute Respiratory Distress Syndrome (ARDS)

• Cardiogenic pulmonary edema

• Viral pneumonitis

• Lymphangitic carcinomatosis

Acute Scrotum

• Testicular torsion

• Epididymitis

• Testicular neoplasm

• Orchitis

• Other: referred pain, hernia, urolithiasis

Addison’s Disease (Primary Adrenocortical Insufficiency)

• Sepsis

• Hypovolemic shock

• Acute abdomen

• Apathetic hyperthyroidism in the elderly

• Myopathies

• GI malignant neoplasm

• Major depression

• Anorexia nervosa

• Hemochromatosis

• Salt-losing nephritis

• Chronic infection

Adnexal Mass ²⁷

• Ovary (neoplasm, endometriosis, functional cyst)

• Fallopian tube (ectopic pregnancy, neoplasm, tubo-ovarian abscess, hydrosalpinx, paratubal cyst)

• Uterus (fibroid, neoplasm)

• Retroperitoneum (neoplasm, abdominal wall hematoma or abscess)

• Urinary tract (pelvic kidney, distended bladder, urachal cyst)

• Inflammatory bowel disease (IBD)

• GI tract neoplasm

• Diverticular disease

• Appendicitis

• Bowel loop with feces

Adrenal Masses ³⁷

UNILATERAL ADRENAL MASS

• Functional lesions: adrenal adenoma; adrenal carcinoma; pheochromocytoma; primary aldosteronism, adenomatous type

• Nonfunctional lesions: incidentaloma of adrenal, ganglioneuroma, myelolipoma, hematoma, adenolipoma, metastasis

BILATERAL ADRENAL MASS

• Functional lesions: adrenocorticotropic hormone (ACTH)–dependent Cushing’s syndrome; congenital adrenal hyperplasia; pheochromocytoma; Conn’s syndrome, hyperplastic variety; micronodular adrenal disease; idiopathic bilateral adrenal hypertrophy

• Nonfunctional lesions: infection (tuberculosis, fungi), infiltration (leukemia, lymphoma), replacement (amyloidosis), hemorrhage, bilateral metastases

Adynamic Ileus ²⁷

• Abdominal trauma

• Infection (retroperitoneal, pelvic, intrathoracic)

• Laparotomy

• Metabolic disease (hypokalemia)

• Renal colic

• Skeletal injury (rib fracture, vertebral fracture)

• Medications (e.g., narcotics)

Aerophagia (Belching, Eructation)

• Anxiety disorders

• Rapid food ingestion

• Carbonated beverages

• Nursing infants (especially when nursing in horizontal position)

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