Daytime Sleepiness

• Medication induced (e.g., benzodiazepines, β-blockers, narcotics, sedative antidepressants, gabapentin)

• Medical illness (e.g., severe anemia, hypothyroidism, COPD, hepatic failure, renal insufficiency, CHF, electrolyte disturbances)

• Circadian rhythm abnormalities (e.g., jet lag, shift work sleep disorder)

• Restless legs syndrome

• Post trauma

• Narcolepsy

• Neurologic disorders (e.g., neurodegenerative disorders; parkinsonism; multiple sclerosis; lesions affecting thalamus, hypothalamus, or brainstem)

Decubitus Ulcer

• Stasis ulcer

• Burns

• Contact dermatitis

• Pyoderma gangrenosum

• Squamous cell carcinoma

• Bullous pemphigoid

• Traumatic ulcer

Delirium ²⁷

METABOLIC DISORDERS

INFLAMMATORY DISORDERS

• Sarcoidosis

• Systemic lupus erythematosus (SLE)

• Giant cell arteritis

ORGAN FAILURE

• Hepatic encephalopathy

• Uremia

DEFICIENCY STATES

• Niacin

• Thiamine, vitamin B₁₂, and folate

Delirium, Dialysis Patient ²⁷

STRUCTURAL

• Cerebrovascular accident (CVA) (particularly hemorrhage)

• Subdural hematoma

• Intracerebral abscess

• Brain tumor

Dementia with Lewy Bodies

• Parkinson’s disease dementia (PDD): differentiated from DLB, in which dementia usually precedes parkinsonism. A somewhat arbitrary “1-year” rule is sometimes used to differentiate DLB from PDD in that if dementia presents within the first year after the parkinsonism, DLB can still be diagnosed.

• Alzheimer’s disease (AD): differs from DLB, in which visual hallucinations and parkinsonism are prominent.

• Atypical parkinsonian syndromes (multiple systems atrophy, progressive supranuclear palsy, corticobasal degeneration): these syndromes have other features, such as cerebellar degeneration, supranuclear gaze palsy, and asymmetric limb apraxia, that are not seen in DLB.

• Vascular dementia: differs from DLB in that despite the fluctuations in performance seen in DLB, there is no clear history of multiple strokes.

• Frontotemporal dementia (FTD, also known as Pick’s disease)

• Creutzfeldt-Jakob disease (CJD): differs from DLB in that it is usually more rapidly progressive, can have cerebellar signs and symptoms, and often has distinctive EEG abnormalities.

• Toxic-, metabolic-, or pharmacologic-related delirium

Demyelinating Diseases ⁴⁰

MULTIPLE SCLEROSIS (MS)

• Relapsing and chronic progressive forms

• Acute MS

• Neuromyelitis optica (Devic’s disease)

DIFFUSE CEREBRAL SCLEROSIS

• Schilder’s encephalitis periaxialis diffusa

• Baló’s concentric sclerosis

ACUTE DISSEMINATED ENCEPHALOMYELITIS

• After measles, chickenpox, rubella, influenza, mumps

• After rabies or smallpox vaccination

NECROTIZING HEMORRHAGIC ENCEPHALITIS

• Hemorrhagic leukoencephalitis

LEUKODYSTROPHIES

• Krabbe’s globoid leukodystrophy

• Metachromatic leukodystrophy

• Adrenoleukodystrophy

• Adrenomyeloneuropathy

• Pelizaeus-Merzbacher leukodystrophy

• Canavan’s disease

• Alexander’s disease

Dependent Personality

• Dependency and personality changes arising as a consequence of an Axis I disorder, such as mood disorders, social anxiety, panic disorder, and agoraphobia

• Dependency arising as a consequence of a general medical condition

• Most common comorbid Axis I conditions are major depressive and other mood disorders, anxiety disorders, including social phobia, and adjustment disorder.

• Most common comorbid personality disorders are histrionic, avoidant, and borderline. Each of these disorders is characterized by dependent features. Dependent personality disorder (DPD) is distinguished by its predominantly submissive, reactive, and clinging behavior.

• Borderline: also fears abandonment but reacts to abandonment with rage rather than urgent efforts to replace the relationship. Also unstable relationships in borderline.

• Histrionic: also strong need for reassurance with associated clinging, but behavior is flamboyant with active demands for attention rather than docile and self-effacing.

• Avoidant: also experiences strong feelings of inadequacy but avoids contact until certain of acceptance rather than active seeking of connection.

Depression

• Hypothyroidism

• Major organ system disease (e.g., cardiovascular, liver, renal, neuronal diseases) with depressive symptoms

• Elderly patients: frequently coexists with dementia

• Bipolar patients will frequently present with depression, but routine treatment with antidepressant medications may be detrimental in this group.

• Neurosyphilis

de Quervain’s Tenosynovitis

• Carpal tunnel syndrome

• Ostearthritis

• Gout

• Infiltrative tenosynovitis

• Radiculopathy

• Compression neuropathy (e.g., superficial branch of the radial nerve “bracelet syndrome”)

• Infection (e.g., TB, bacterial)

Dermatitis, Atopic

• Scabies

• Psoriasis

• Dermatitis herpetiformis

• Contact dermatitis

• Photosensitivity

• Seborrheic dermatitis

• Candidiasis

• Lichen simplex chronicus

• Other: Wiskott-Aldrich syndrome, phenylketonuria (PKU), mycosis fungoides, ichthyosis, HIV dermatitis, non-nummular eczema, histiocytosis X

Dermatitis, Contact

• Impetigo

• Lichen simplex chronicus

• Atopic dermatitis

• Nummular eczema

• Seborrheic dermatitis

• Psoriasis

• Scabies

Dermatitis Herpetiformis

• Linear IgA bullous dermatosis (not associated with gluten-sensitive enteropathy)

• Herpes simplex infection

• Herpes zoster infection

• Erythema multiforme

• Bullous pemphigoid

Dermatofibroma

• Insect bite

• Foreign body reaction

• Basal cell carcinoma

• Scar

• Keloid

• Nevus

Dermatographism

• Cholinergic urticaria

• Solar urticaria

• Heat urticaria

• Exercise-induced urticaria

• Cold urticaria

• Lupus

• Aquagenic urticaria

• Polymorphous light eruption

Dermatomyositis

• Polymyositis

• Inclusion body myositis

• Muscular dystrophies

• Amyotrophic lateral sclerosis

• Myasthenia gravis

• Eaton-Lambert syndrome

• Drug-induced myopathies

• Diabetic amyotrophy

• Guillain-Barré syndrome

• Hyperthyroidism or hypothyroidism

• Lichen planus

• Systemic lupus erythematosus (SLE)

• Contact dermatitis

• Atopic dermatitis

• Psoriasis

• Seborrheic dermatitis

Dermatosis by Morphology ¹⁶

PAPULES

EROSIONS AND ULCERS

DESQUAMATION

• Exfoliative dermatitis

• Kawasaki’s syndrome

• Keratolysis exfoliativa (hands and feet)

• Scarlet fever

• Scarlatiniform eruption

• Staphylococcal scalded skin syndrome

• Toxic shock syndrome (late)

Dermatosis by Region ¹⁶

SCALP

FACE

HANDS AND FEET

PHOTODISTRIBUTED

• Dermatomyositis

• Lupus erythematosus

• Pellagra

• Photodrug eruption

• Polymorphous light eruption

• Porphyria cutanea tarda

Dermoid Cyst

• Epidermoid cyst

• Nevus sebaceus

• Enlarged lymph node

• Pilomatricoma

Diabetes Insipidus

• Diabetes mellitus (DM), nephropathies

• Primary polydipsia, medications (e.g., chlorpromazine)

• Osmotic diuresis (glucose, mannitol, anticholinergics)

• Psychogenic polydipsia, electrolyte disturbances

Diabetes Mellitus

• Diabetes insipidus

• Stress hyperglycemia

• Diabetes secondary to hormonal excess, drugs, pancreatic disease

• Excessive use of diuretics

Diabetic Ketoacidosis

• Hyperosmolar nonketotic state

• Alcoholic ketoacidosis

• Uremic acidosis

• Metabolic acidosis secondary to methyl alcohol, ethylene glycol

• Salicylate poisoning

Diarrhea, Acute Watery and Bloody ³⁹

ACUTE BLOODY DIARRHEA

• Infectious colitis

• Confluent proctocolitis (e.g., Shigella, Campylobacter, Salmonella, Entamoeba histolytica)

• Segmental colitis (e.g., Campylobacter, Salmonella, enteroinvasive E. coli, Aeromonas, E. histolytica)

• Drug-induced colitis (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs])

• Inflammatory bowel disease

• Ischemic colitis (usually elderly patient with underlying heart disease or arrhythmias)

• Antibiotic-associated colitis

Diarrhea, Tube-Fed Patient ¹⁴

COMMON CAUSES UNRELATED TO TUBE FEEDING

• Elixir medications containing sorbitol

• Magnesium-containing antacids

• Antibiotic-induced sterile gut

• Pseudomembranous colitis

POSSIBLE CAUSES RELATED TO TUBE FEEDING

• Inadequate fiber to form stool bulk

• High fat content of formula (in the presence of fat malabsorption syndrome)

• Bacterial contamination of enteral products and delivery systems (causal association with diarrhea not documented)

• Rapid advancement in rate (after the GI tract is unused for prolonged periods)

UNLIKELY CAUSES RELATED TO TUBE FEEDING

• Formula hyperosmolality (proven not to be the cause of diarrhea)

• Lactose (absent from nearly all enteral feeding formulas)

Diffuse Interstitial Lung Disease

• Congestive heart failure (CHF)

• Chronic renal failure

• Lymphangitic carcinomatosis

• Sarcoidosis

• Allergic alveolitis

Digitalis Overdose

• Medications

• β-Blockers

• Calcium channel blockers

• Clonidine

• Cyclic antidepressants

• Encainide and flecainide

• Procainamide

• Propoxyphene

• Quinidine

• Plants producing digitalis-like glycosides

• Foxglove

• Oleander

• Lily of the valley

• Cardiac conduction abnormalities

• Sick sinus syndrome

• AV node dysfunction

• Electrolyte abnormalities

• Hyperkalemia

Diphtheria

• Streptococcal pharyngitis

• Viral pharyngitis

• Mononucleosis

Diplopia, Binocular

• Cranial nerve palsy (third, fourth, sixth)

• Thyroid eye disease

• Myasthenia gravis

• Decompensated strabismus

• Orbital trauma with blowout fracture

• Orbital pseudotumor

• Cavernous sinus thrombosis

Diplopia, Monocular

• Postoperative corrected long-standing tropia

• Defective contact lenses

• Poorly fitting bifocals

• Trauma to iris

• Corneal disorder (e.g., dry eye, astigmatism)

• Foreign body in aqueous or vitreous media

• Migraine

• Lesions of occipital cortex

• Psychogenic

Diplopia, Vertical

• Myasthenia

• Superior oblique palsy

• Myositis or pseudotumor with orbital involvement

• Lymphoma or metastases affecting the orbits

• Brainstem or cerebellar lesions

• Hydrocephalus

• Third nerve palsy

• Botulism

• Wernicke’s encephalopathy

• Dysthyroid orbitopathy (muscle infiltration)

Discoid Lupus Erythematosus (DLE)

• Psoriasis

• Lichen planus

• Secondary syphilis

• Superficial fungal infections

• Photosensitivity eruption

• Sarcoidosis

• Subacute cutaneous lupus erythematosus

Disseminated Intravascular Coagulation (DIC)

• Hepatic necrosis: normal or elevated factor VIII concentrations

• Vitamin K deficiency: normal platelet count

• Hemolytic-uremic syndrome (HUS)

• Thrombocytopenic purpura

• Renal failure, systemic lupus erythematosus (SLE), sickle cell crisis, dysfibrinogenemias

Diverticular Disease

• Irritable bowel syndrome (IBS)

• Inflammatory bowel disease (IBD)

• Carcinoma of colon

• Endometriosis

• Ischemic colitis

• Infections (pseudomembranous colitis, appendicitis, pyelonephritis, pelvic inflammatory disease [PID])

• Lactose intolerance

Dizziness

• Viral syndrome

• Anxiety, hyperventilation

• Benign positional paroxysmal vertigo

• Medications (e.g., sedatives, antihypertensives, analgesics)

• Withdrawal from medications (e.g., benzodiazepines, SSRIs)

• Alcohol or drug abuse

• Postural hypotension

• Hypoglycemia, hyperglycemia

• Hematologic disorders (e.g., anemia, polycythemia, leukemia)

• Head trauma

• Meniere’s disease

• Vertebrobasilar ischemia

• Cervical osteoarthritis

• Cardiac abnormalities (arrhythmias, cardiomyopathy, CHF, pericarditis)

• Multiple sclerosis

• Peripheral vestibulopathy

• Air or sea travel

• Electrolyte abnormalities

• Eye problems (cornea, lens, retina)

• Migraine

• Brainstem infarct

• Autonomic neuropathy

• Chronic otomastoiditis

• Complex partial seizures

• Ramsay Hunt syndrome

• Arteritis

• Syncope and presyncope

• Perilymph fistula

• Cerebellopontine tumor

• Hepatic or renal disease

Drug Eruption

• Scarlet fever

• Measles

• Rubella

• Viral exanthem such as enterovirus, echovirus, cytomegalovirus

• Kawasaki’s disease

• Juvenile rheumatoid arthritis

• Secondary syphilis

• Primary HIV disease

Dry Eye

• Contacts

• Medications (antihistamines, clonidine, β-blockers, ibuprofen, scopolamine)

• Keratoconjunctivitis sicca

• Trauma

• Environmental causes (air-conditioning in patient with contacts)

Dumping Syndrome

• Pancreatic insufficiency

• Inflammatory bowel disease (IBD)

• Afferent loop syndromes

• Bile acid reflux after surgery

• Bowel obstruction

• Gastroenteric fistula

Dysfunctional Uterine Bleeding

• Pregnancy-related cause

• Anatomic uterine causes: leiomyomas, adenomyosis, polyps, endometrial hyperplasia, cancer, STDs, intrauterine contraceptive device (IUD)

• Anatomic nonuterine causes: cervical neoplasia, cervicitis; vaginal neoplasia, adhesions, trauma, foreign body, atrophic vaginitis, infections, condyloma; vulvar trauma, infections, neoplasia, condyloma, dystrophy, varices

• Urinary tract: urethral caruncle, diverticulum, hematuria

• GI tract: hemorrhoids, anal fissure, colorectal lesions

• Systemic diseases: exogenous hormone intake, renal disease

• Coagulopathies: von Willebrand disease, thrombocytopenia, hepatic failure

• Endocrinopathies: thyroid disorder, hypothyroidism and hyperthyroidism, diabetes mellitus (DM)

Dysmenorrhea

• Adenomyosis

• Adhesions

• Allen-Masters syndrome

• Cervical strictures or stenosis

• Congenital malformation of müllerian system

• Ectopic pregnancy

• Endometriosis, endometritis

• Imperforate hymen

• Intrauterine contraceptive device (IUD) use

• Leiomyomas

• Ovarian cysts

• Pelvic congestion syndrome, pelvic inflammatory disease (PID)

• Polyps

• Transverse vaginal septum

Dyspareunia ¹²

MIDVAGINAL

• Inadequate lubrication

DEEP

• Endometriosis

• Pelvic infection

• Uterine retroversion

• Ovarian pathology

• Gastrointestinal

• Orthopedic

• Abnormal penile size or shape

Dyspepsia, Nonulcerative

Other possible causes of dyspepsia:

• Peptic ulcer disease

• Gastroesophageal reflux

• Gastric, esophageal, and all abdominal cancers

• Biliary tract disease

• Gastroparesis

• Pancreatitis

• Medications (i.e., NSAIDs, erythromycin, steroids)

• Infiltrative diseases of the stomach (i.e., Crohn’s disease or sarcoidosis)

• Metabolic disturbances (i.e., hypercalcemia or hyperkalemia)

• Ischemic bowel disease

• System disorders (i.e., diabetes, thyroid disorders, or connective tissue diseases)

Dysphagia

• Esophageal obstruction: neoplasm, foreign body, achalasia, stricture, spasm, esophageal web, diverticulum, Schatzki’s ring

• Peptic esophagitis with stricture, Barrett’s stricture

• External esophageal compression: neoplasms (thyroid neoplasm, lymphoma, mediastinal tumors), thyroid enlargement, aortic aneurysm, vertebral spurs, aberrant right subclavian artery (dysphagia lusoria)

• Hiatal hernia, gastroesophageal reflux disease (GERD)

• Oropharyngeal lesions: pharyngitis, glossitis, stomatitis, neoplasms

• Hysteria: globus hystericus

• Neurologic or neuromuscular disturbances: bulbar paralysis, myasthenia gravis, amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), parkinsonism, cerebrovascular accident (CVA), diabetic neuropathy

• Toxins: poisoning, botulism, tetanus, post-diphtheritic dysphagia

• Systemic diseases: scleroderma, amyloidosis, dermatomyositis

• Candida and herpes esophagitis

• Presbyesophagus

Dyspnea

• Upper airway obstruction: trauma, neoplasm, epiglottitis, laryngeal edema, tongue retraction, laryngospasm, abductor paralysis of vocal cords, aspiration of foreign body

• Lower airway obstruction: neoplasm, chronic obstructive pulmonary disease (COPD), asthma, aspiration of foreign body

• Pulmonary infection: pneumonia, abscess, empyema, TB, bronchiectasis

• Pulmonary hypertension

• Pulmonary embolism/infarction

• Parenchymal lung disease

• Pulmonary vascular congestion

• Cardiac disease: arteriosclerotic heart disease (ASHD), valvular lesions, cardiac dysrhythmias, cardiomyopathy, pericardial effusion, cardiac shunts

• Space-occupying lesions: neoplasm, large hiatal hernia, pleural effusions

• Disease of chest wall: severe kyphoscoliosis, fractured ribs, sternal compression, morbid obesity

• Neurologic dysfunction: Guillain-Barré syndrome, botulism, polio, spinal cord injury

• Interstitial pulmonary disease: sarcoidosis, collagen-vascular diseases, desquamative interstitial pneumonia (DIP), Hamman-Rich pneumonitis, others

• Pneumoconioses: silicosis, berylliosis, others

• Mesothelioma

• Pneumothorax, hemothorax, pleural effusion

• Inhalation of toxins

• Cholinergic drug intoxication

• Carcinoid syndrome

• Hematologic: anemia, polycythemia, hemoglobinopathies

• Thyrotoxicosis, myxedema

• Diaphragmatic compression caused by abdominal distention, subphrenic abscess, ascites

• Lung resection

• Metabolic abnormalities: uremia, hepatic coma, diabetic ketoacidosis (DKA)

• Sepsis

• Atelectasis

• Psychoneurosis

• Diaphragmatic paralysis

• Pregnancy

Dystonia

• Parkinson’s disease

• Progressive supranuclear palsy

• Wilson’s disease

• Huntington’s disease

• Drug effects

Dysuria

• Urinary tract infection (UTI)

• Estrogen deficiency (in postmenopausal woman)

• Vaginitis

• Genital infection (e.g., herpes, condyloma)

• Interstitial cystitis

• Chemical irritation (e.g., deodorant aerosols, douches)

• Meatal stenosis or stricture

• Reiter’s syndrome

• Bladder neoplasm

• GI (diverticulitis, Crohn’s disease)

• Impaired bladder or sphincter action

• Urethral carbuncle

• Chronic fibrosis post trauma

• Radiation therapy

• Prostatitis

• Urethritis (gonococcal, chlamydial)

• Behçet’s syndrome

• Stevens-Johnson syndrome

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