Hairy Tongue

• Oral hairy leukoplakia

• Candidiasis

• Lichen planus

• Stomatitis

Halitosis

• Tobacco use

• Alcohol use

• Dry mouth (mouth breathing, inadequate fluid intake)

• Foods (onion, garlic, meats, nuts)

• Disease of mouth or nose (infections, cancer, inflammation)

• Medications (antihistamines, antidepressants)

• Systemic disorders (diabetes, uremia)

• GI disorders (esophageal diverticula, hiatal hernia, gastroesophageal reflux disease [GERD], achalasia)

• Sinusitis

• Pulmonary disorders (bronchiectasis, pneumonia, neoplasms, TB)

Hand-Foot-Mouth Disease

• Aphthous stomatitis

• Herpes simplex infection

• Herpangina

• Erythema multiforme

• Allergic contact dermatitis

Hand Pain and Swelling ⁵

• Deep venous thrombosis (DVT) of upper extremity

• Thrombophlebitis

• Rheumatoid arthritis (RA)

• Remitting seronegative symmetric synovitis with pitting edema

• Polymyalgia rheumatica

• Mixed connective tissue disease

• Scleroderma

• Rupture of the olecranon bursa

• Medsger’s syndrome (neoplasia)

• The puffy hand of drug addiction

• Reflex sympathetic dystrophy

• Eosinophilic fasciitis

• Sickle cell (hand-foot syndrome)

• Leprosy

• Factitial (the rubber band syndrome)

Headache ¹³

• Vascular: migraine, cluster headaches, temporal arteritis, hypertension, cavernous sinus thrombosis

• Musculoskeletal: neck and shoulder muscle contraction, strain of extraocular or intraocular muscles, cervical spondylosis, temporomandibular arthritis

• Infections: meningitis, encephalitis, brain abscess, sepsis, sinusitis, osteomyelitis, parotitis, mastoiditis

• Cerebral neoplasm

• Subdural hematoma

• Cerebral hemorrhage/infarct

• Pseudotumor cerebri

• Normal-pressure hydrocephalus (NPH)

• Post lumbar puncture

• Cerebral aneurysm, arteriovenous malformations

• Post trauma

• Dental problems: abscess, periodontitis, poorly fitting dentures

• Trigeminal neuralgia, glossopharyngeal neuralgia

• Otitis and other ear diseases

• Glaucoma and other eye diseases

• Metabolic: uremia, carbon monoxide inhalation, hypoxia

• Pheochromocytoma, hypoglycemia, hypothyroidism

• Effort induced: benign exertional headache, cough headache, coital cephalalgia

• Drugs: alcohol, nitrates, histamine antagonists

• Paget’s disease of the skull

• Emotional, psychiatric

Headache, Acute ¹¹

DIFFERENTIAL DIAGNOSIS OF ACUTE HEADACHE

Evaluation of the first acute headache should exclude pathologic causes listed here before consideration of more common etiologies.

• Increased intracranial pressure (ICP): trauma, hemorrhage, tumor, hydrocephalus, pseudotumor cerebri, abscess, arachnoid cyst, cerebral edema

• Decreased ICP: after ventriculoperitoneal shunt, lumbar puncture, cerebrospinal fluid leak from basilar skull fracture

• Meningeal inflammation: meningitis, leukemia, subarachnoid or subdural hemorrhage

• Vascular: vasculitis, arteriovenous malformation, hypertension, cerebrovascular accident

• Bone, soft tissue: referred pain from scalp, eyes, ears, sinuses, nose, teeth, pharynx, cervical spine, temporomandibular joint

• Infection: systemic infection, encephalitis, sinusitis, others

• First migraine

Headache and Facial Pain ³⁷

VASCULAR HEADACHES

• Cluster headaches

• Episodic cluster headache (“cyclic cluster headaches”)

• Chronic cluster headaches

• Chronic paroxysmal hemicrania

HEADACHES ASSOCIATED WITH DEMONSTRABLE MUSCLE SPASM

• Headache caused by posturally induced or paralesional muscle spasm

• Headaches of sustained or impaired posture (e.g., prolonged close work, driving)

• Headaches associated with cervical spondylosis and other diseases of cervical spine

• Myofascial pain dysfunction syndrome (headache or facial pain associated with disorders of teeth, jaws, and related structures, or “temporomandibular joint [TMJ] syndrome”)

• Headaches caused by psychophysiologic muscle contraction (“muscle contraction headaches,” or tension type of headache associated with disorder of pericranial muscles)

HEADACHES AND FACIAL PAIN WITHOUT DEMONSTRABLE PHYSICAL SUBSTRATE

• Headaches of uncertain etiology: “tension headaches” (tension type of headache unassociated with disorder of pericranial muscles)

• Some forms of post-traumatic headache

• Psychogenic headaches (e.g., hypochondriacal, conversional, delusional, malingering)

• Facial pain of uncertain etiology (“atypical facial pain”)

COMBINED TENSION-MIGRAINE HEADACHES

• Episodic migraine superimposed on chronic tension headaches

• Chronic daily headaches: associated with analgesic or ergotamine overuse (“rebound headaches”)

• Not associated with drug overuse

HEADACHES AND HEAD PAINS CAUSED BY DISEASES OF EYES, EARS, NOSE, SINUSES, TEETH, OR SKULL

HEADACHES CAUSED BY MENINGEAL INFLAMMATION

• Subarachnoid hemorrhage

• Meningitis and meningoencephalitis

• Others (e.g., meningeal carcinomatosis)

Headache, Cluster

• Migraine

• Trigeminal neuralgia

• Temporal arteritis

• Postherpetic neuralgia

• Pheochromocytoma

• Glaucoma

Headache, Migraine

• Subarachnoid hemorrhage

• Cluster headache

• Chronic daily headaches (including drug rebound headaches)

• Arteriovenous malformation

• Vasculitis

• Intracranial mass lesion

Headache, Tension Type

• Migraine (would expect associated symptoms; see Headache, Migraine)

• Cervical spine disease

• Intracranial mass (may present with focal neurologic signs, seizures, or headache awakening patient from sleep)

• Idiopathic intracranial hypertension (found more often in obese women of childbearing age; may have papilledema, visual loss, or diplopia)

• Rebound headache from overuse of analgesics

• Secondary headache (e.g., temporomandibular joint syndrome, thyrotoxicosis, polycythemia, drug side effects)

• Migraine and tension-type headache may often coexist and may be difficult to differentiate (suggest headache calendar).

Head and Neck, Soft Tissue Masses

• Lipoma

• Pilar cyst

• Epidermal inclusion cyst

• Dermoid cyst

• Bone cyst

• Hemangioma

• Eosinophilic granuloma

• Other: facial nerve neuroma, teratoma, rhabdomyoma, rhabdomyosarcoma, branchial cleft cyst

Hearing Loss, Acute ²⁷

• Infectious: mumps, measles, influenza, herpes simplex, herpes zoster, cytomegalovirus (CMV), mononucleosis, syphilis

• Vascular: macroglobulinemia, sickle cell disease, Berger’s disease, leukemia, polycythemia, fat emboli, hypercoagulable states

• Metabolic: diabetes, pregnancy, hyperlipoproteinemia

• Conductive: cerumen impaction, foreign bodies, otitis media, otitis externa, barotrauma, trauma

• Medications: aminoglycosides, loop diuretics, antineoplastics, salicylates, vancomycin

• Neoplasm: acoustic neuroma, metastatic neoplasm

Heartburn and Indigestion ³⁴

• Reflux esophagitis

• Gastritis

• Nonulcer dyspepsia

• Functional GI disorder (anxiety disorder, social/environmental stresses)

• Excessive intestinal gas (ingestion of flatulogenic foods, GI stasis, constipation)

• Gas entrapment (hepatitis or splenic flexure syndrome)

• Neoplasm (adenocarcinoma of stomach or esophagus, lymphoma)

• Gallbladder disease

Heart Failure, Pregnancy

• Congenital valvular heart disease exacerbated by pregnancy

• Peripartum cardiomyopathy

• Untreated thyrotoxicosis

• Hypothyroidism

• Pulmonary hypertension

• Myocardial infarction

Heat Illness

• Infections (meningitis, encephalitis, sepsis)

• Head trauma

• Epilepsy

• Thyroid storm

• Acute cocaine intoxication

• Malignant hyperthermia

• Heat exhaustion can be differentiated from heat stroke by the following:

• Essentially intact mental function and lack of significant fever in heat exhaustion

• Mild or absent increases in creatine kinase (CK), aspartate transaminase (AST), lactate dehydrogenase (LDH), and alanine aminotransferase (ALT) in heat exhaustion

Heel Pain

• Achilles tendinitis/tendinopathy (insertional, noninsertional)

• Retrocalcaneal bursitis (superficial, deep)

• Plantar fasciopathy

• Neuropathy (tarsal tunnel, posterior tibial nerve [medial calcaneal branch], abductor digiti quinti)

• Calcaneal stress fracture

• Puncture wound, foreign body

• Cellulitis

• Spondyloarthropathy

• Fat pad atrophy

• Soft tissue tumor

• S1 radiculopathy

• Paget’s disease of bone

• Haglund deformity

• Primary or metastatic bone tumor

Heel Pain, Plantar ²⁵

SKIN

FAT

• Atrophy

• Panniculitis

DENSE CONNECTIVE TISSUE

• Inflammatory fasciitis

• Fibromatosis

• Enthesopathy

• Bursitis

BONE (CALCANEUS)

• Stress fracture

• Paget’s disease

• Benign bone cyst/tumor

• Malignant bone tumor

• Metabolic bone disease (osteopenia)

NERVE

• Tarsal tunnel

• Plantar nerve entrapment

• S1 nerve root radiculopathy

• Painful peripheral neuropathy

INFECTION

• Dermatomycoses

• Acute osteomyelitis

• Plantar abscess

MISCELLANEOUS

• Foreign body

• Nonunion calcaneus fracture

• Psychogenic

• Idiopathic

HELLP Syndrome

• Appendicitis

• Gallbladder disease

• Systemic lupus erythematosus (SLE)

• Thrombotic thrombocytopenic purpura

• Hemolytic-uremic syndrome (HUS)

• Acute fatty liver of pregnancy

Hemarthrosis

• Trauma

• Anticoagulant therapy

• Thrombocytopenia, thrombocytosis

• Bleeding disorders (e.g., von Willebrand disease)

• Charcot’s joint

• Idiopathic

• Other: pigmented villonodular synovitis, hemangioma, synovioma, arteriovenous (AV) fistula, ruptured aneurysm

Hematemesis ³⁹

Causes of hematemesis:

VERY COMMON

• Gastric or duodenal ulcer or erosions

COMMON

• Mallory-Weiss tear (a laceration at the gastroesophageal junction)

• Ulcerative esophagitis

• Esophageal varices

UNCOMMON

• Vascular malformations

• Ulcerated gastrointestinal stromal tumor

• Carcinoma of esophagus or stomach

• Aortoenteric fistula

Hematuria

Use the mnemonic TICS:

• T

• Trauma: blow to kidney, insertion of Foley catheter or foreign body in urethra, prolonged and severe exercise, very rapid emptying of overdistended bladder

• Tumor: hypernephroma, Wilms’ tumor, papillary carcinoma of the bladder, prostatic and urethral neoplasms

• Toxins: turpentine, phenols, sulfonamides and other antibiotics, cyclophosphamide, nonsteroidal anti-inflammatory drugs (NSAIDs)

• I

• Infections: glomerulonephritis, TB, cystitis, prostatitis, urethritis, Schistosoma haematobium, yellow fever, blackwater fever

• Inflammatory processes: Goodpasture’s syndrome, periarteritis, post irradiation

• C

• Calculi: renal, ureteral, bladder, urethra

• Cysts: simple cysts, polycystic disease

• Congenital anomalies: hemangiomas, aneurysms, arteriovenous malformation (AVM)

• S

• Surgery: invasive procedures, prostatic resection, cystoscopy

• Sickle cell disease and other hematologic disturbances: hemophilia, thrombocytopenia, anticoagulants

• Somewhere else: bleeding genitals, factitious (drug addicts)

Hematuria, Cause by Age and Sex

0–20 YEARS

• Acute urinary tract infection (UTI)

• Acute glomerulonephritis

• Congenital urinary tract anomalies with obstruction

• Trauma to genitals

20–40 YEARS

40–60 YEARS (WOMEN)

• Acute UTI

• Bladder cancer

• Urolithiasis

40–60 YEARS (MEN)

• Acute UTI

• Bladder cancer

• Urolithiasis

60 YEARS AND OLDER (WOMEN)

• Acute UTI

• Bladder cancer

• Vaginal trauma or irritation

• Urolithiasis

60 YEARS AND OLDER (MEN)

• Acute UTI

• Benign prostatic hyperplasia

• Bladder cancer

• Urolithiasis

• Trauma

Hemiparesis/Hemiplegia

• Cerebrovascular accident (CVA)

• Transient ischemic attack (TIA)

• Cerebral neoplasm

• Multiple sclerosis (MS) or other demyelinating disorder

• Metabolic (hyperosmolar state, electrolyte imbalance)

• Psychiatric disorders

• Congenital disorders

• Leukodystrophies

• Acute fatty liver of pregnancy

Hemochromatosis

• Hereditary anemias with defect of erythropoiesis

• Cirrhosis

• Repeated blood transfusions

Hemolysis and Hemoglobinuria

• Erythrocyte trauma (prosthetic cardiac valves, marching and severe trauma, extensive burns)

• Infections (malaria, Bartonella, Clostridium welchii)

• Brown recluse spider bite

• Incompatible blood transfusions

• Hemolytic-uremic syndrome (HUS)

• Thrombotic thrombocytopenic purpura (TTP)

• Paroxysmal nocturnal hemoglobinuria (PNH)

• Drugs (penicillins, quinidine, methyldopa, sulfonamides, nitrofurantoin)

• Erythrocyte enzyme deficiencies (e.g., exposure to fava beans in patients with glucose-6-phosphate dehydrogenase [G6PD] deficiency)

Hemolysis, Intravascular

• Infections

• Exertional hemolysis (e.g., prolonged march)

• Valve hemolysis

• Microangiopathic hemolytic anemia

• Osmotic and chemical agents

• Thermal injury

• Cold agglutinins

• Venoms (snakes, spiders)

• Paroxysmal nocturnal hemoglobinuria (PNH)

Hemolysis, Mechanical

• Prosthetic heart valves

• Aortic stenosis

• Malignant hypertension

• Metastatic adenocarcinoma

• Traumatic exercise

• Renal transplants

• Renal cortical necrosis

• Glomerulonephritis

• Thrombotic thrombocytopenic purpura (TTP), hemolytic-uremic syndrome (HUS)

• Renal vasculitis

• Scleroderma

• Diabetes

Hemolytic-Uremic Syndrome (HUS)

• The differential is vast, including all causes of bloody and nonbloody diarrhea, because the GI symptoms usually precede the triad of HUS.

• Thrombotic thrombocytopenic purpura

• Disseminated intravascular coagulation

• Prosthetic valve hemolysis

• Malignant hypertension

• Vasculitis

Hemoperitoneum

• Ruptured graafian follicle

• Ruptured spleen

• Ectopic pregnancy

• Traumatic laceration of liver

• Ruptured aneurysm

• Ruptured bladder

• Traumatic laceration of bowel, pancreas, uterus

Hemophilia

• Other clotting factor deficiencies

• Platelet function disorders

• Vitamin K deficiency

• Anticoagulant overdose

Hemoptysis

CARDIOVASCULAR

• Pulmonary embolism/infarction

• Left ventricular (LV) failure

• Mitral stenosis

• Arteriovenous (AV) fistula

• Severe hypertension

• Erosion of aortic aneurysm

PULMONARY

• Neoplasm (primary or metastatic)

• Infection

• Pneumonia: Streptococcus pneumoniae, Klebsiella pneumoniae, Staphylococcus aureus, Legionella pneumophila

• Fungal infections (aspergillosis, coccidioidomycosis)

• Parasitic infections (amebiasis, ascariasis, paragonimiasis)

• Vasculitis: Wegener’s granulomatosis, Churg-Strauss syndrome, Henoch-Schönlein purpura

• Goodpasture’s syndrome

• Trauma (needle biopsy, foreign body, right-sided heart catheterization, prolonged and severe cough)

• Cystic fibrosis (CF), bullous emphysema

• Pulmonary sequestration

• Pulmonary arteriovenous (AV) fistula

• Systemic lupus erythematosus (SLE)

• Idiopathic pulmonary hemosiderosis

• Drugs: aspirin, anticoagulants, penicillamine

• Pulmonary hypertension

• Mediastinal fibrosis

OTHER

• Epistaxis, trauma

• Laryngeal bleeding (laryngitis, laryngeal neoplasm)

• Hematologic disorders (clotting abnormalities, disseminated intravascular coagulation [DIC], thrombocytopenia)

Hemorrhoids

• Fissure

• Abscess

• Anal fistula

• Condylomata acuminata

• Hypertrophied anal papillae

• Rectal prolapse

• Rectal polyp

• Neoplasm

Hemosiderinuria

• Paroxysmal nocturnal hemoglobinuria (PNH)

• Chronic hemolytic anemia

• Hemochromatosis

• Blood transfusion

• Thalassemias

Henoch-Schönlein Purpura

• Polyarteritis nodosa

• Meningococcemia

• Thrombocytopenic purpura

• Viral syndrome

Hepatic Coma

• Delirium secondary to medications or illicit drugs

• Cerebrovascular accident (CVA), subdural hematoma

• Meningitis, encephalitis

• Metastatic neoplasm to brain

• Alcohol withdrawal syndrome

Hepatic Cysts ³⁷

CONGENITAL HEPATIC CYSTS

• Parenchymal: solitary cyst, polycystic disease

• Ductal: localized dilatation, multiple cystic dilatations of intrahepatic ducts (Caroli’s disease)

ACQUIRED HEPATIC CYSTS

• Inflammatory cysts: retention cysts, echinococcal cyst, amebic cyst

• Neoplastic cyst

• Peliosis hepatis

Hepatic Encephalopathy

• Delirium caused by medications or illicit drugs

• Cerebrovascular accident, subdural hematoma

• Meningitis, encephalitis

• Metastatic neoplasm to brain

• Alcohol withdrawal syndrome

Hepatic Granulomas ¹

INFECTIONS

• Bacterial, spirochetal: TB and atypical mycobacterial infections, tularemia, brucellosis, leprosy, syphilis, Whipple’s disease, listeriosis

• Viral: mononucleosis, cytomegalovirus (CMV)

• Rickettsial: Q fever

• Fungal: coccidioidomycosis, histoplasmosis, cryptococcal infections, actinomycosis, aspergillosis, nocardiosis

• Parasitic: schistosomiasis, clonorchiasis, toxocariasis, ascariasis, toxoplasmosis, amebiasis

HEPATOBILIARY DISORDERS

• Primary biliary cirrhosis, granulomatous hepatitis, jejunoileal bypass

SYSTEMIC DISORDERS

• Sarcoidosis, Wegener’s granulomatosis, inflammatory bowel disease, Hodgkin’s disease, lymphoma

DRUGS/TOXINS

• Beryllium, parenteral foreign material (e.g., starch, talc, methyldopa, procainamide, allopurinol, α-silicone), phenylbutazone, phenytoin, nitrofurantoin, hydralazine

Hepatitis, Acute ²⁶

NONINFECTIOUS

• Drug induced

• Autoimmune

• Ischemic

• Acute fatty liver of pregnancy

• Acute Budd-Chiari syndrome

• Wilson’s disease

Hepatitis, Autoimmune

• Acute viral hepatitis (A, B, C, D, E; cytomegalovirus [CMV], Epstein-Barr virus, herpes)

• Chronic viral hepatitis (B, C)

• Toxic hepatitis (alcohol, drugs)

• Primary biliary cirrhosis

• Primary sclerosing cholangitis

• Hemochromatosis

• Nonalcoholic steatohepatitis

• Systemic lupus erythematosus (SLE)

• Wilson’s disease

• α₁-Antitrypsin deficiency

Hepatitis, Chronic ²⁶

• Chronic viral hepatitis

• Hepatitis B

• Hepatitis C

• Hepatitis D

• Autoimmune hepatitis and variant syndromes

• Hereditary hemochromatosis

• Wilson’s disease

• α₁-Antitrypsin deficiency

• Fatty liver and nonalcoholic steatohepatitis

• Alcoholic liver disease

• Drug-induced liver disease

Hepatitis A

• Other hepatitis virus (B, C, D, E)

• Infectious mononucleosis

• Cytomegalovirus (CMV) infection

• Herpes simplex virus infection

• Leptospirosis

• Brucellosis

• Drug-induced liver disease

• Ischemic hepatitis

• Autoimmune hepatitis

Hepatitis B

• Other hepatitis virus (A, C, D, E)

• Infectious mononucleosis

• Cytomegalovirus (CMV) infection

• Herpes simplex virus infection

• Leptospirosis

• Brucellosis

• Drug-induced liver disease

• Ischemic hepatitis

• Autoimmune hepatitis

Hepatitis C

• Other hepatitis virus (A, B, D, E)

• Infectious mononucleosis

• Cytomegalovirus (CMV) infection

• Herpes simplex virus infection

• Leptospirosis

• Brucellosis

• Drug-induced liver disease

• Ischemic hepatitis

• Autoimmune hepatitis

Hepatitis D

• Other hepatitis virus (A, B, C, E)

• Infectious mononucleosis

• Cytomegalovirus (CMV) infection

• Herpes simplex virus infection

• Leptospirosis

• Brucellosis

• Drug-induced liver disease

• Ischemic hepatitis

• Autoimmune hepatitis

Hepatitis E

• Other hepatitis virus (A, B, C, D)

• Infectious mononucleosis

• Cytomegalovirus (CMV) infection

• Herpes simplex virus infection

• Leptospirosis

• Brucellosis

• Drug-induced liver disease

• Ischemic hepatitis

• Autoimmune hepatitis

Hepatocellular Carcinoma

• Metastatic neoplasm to liver

• Benign liver tumors (adenomas)

• Focal nodular hyperplasia

• Hemangiomas

• Focal fatty infiltration

Hepatomegaly

Hepatomegaly, by Shape of Liver ³⁹

DIFFUSELY ENLARGED AND IRREGULAR

• Metastatic disease

• Cirrhosis

• Hydatid disease

• Polycystic liver disease

LOCALIZED SWELLINGS

• Riedel’s lobe (a normal variant; the lobe may be palpable in the right lumbar region)

• Metastasis

• Large simple hepatic cyst

• Hydatid cyst

• Hepatoma

• Liver abscess (e.g., amebic abscess)

Hepatorenal Syndrome

• Prerenal azotemia: response to sustained plasma expansion is good (prompt diuresis with volume expansion).

• Acute tubular necrosis: urinary sodium >30, FE_Na >1.5%, urinary/plasma creatinine ratio <30, urine/plasma osmolality ratio = 1, urine sediment reveals casts and cellular debris; there is no significant response to sustained plasma expansion.

Hermaphroditism ⁴

MALE PSEUDOHERMAPHRODITISM

• Defect in androgen action

• 5α-Reductase 2 mutations

• Androgen receptor defects

• Complete androgen insensitivity syndrome

• Partial androgen insensitivity syndrome

Reifenstein’s and other syndromes

Smith-Lemli-Opitz syndrome

• Defect in conversion of 7-dehydrocholesterol to cholesterol

TRUE HERMAPHRODITISM

• XX

• XY

• XX/XY chimeras

Herpangina

• Herpes simplex

• Bacterial pharyngitis

• Tonsillitis

• Aphthous stomatitis

• Hand-foot-mouth disease

Herpes Simplex, Genital

• Human papillomavirus

• Molluscum contagiosum

• HIV infection

• Fungal infections (Candida)

• Bacterial infections (syphilis, chancroid, granuloma inguinale)

• Follicular abscess

• Hidradenitis suppurativa

• Vulvar dystrophies

• Cancer of the vulva

Herpes Simplex, Oral

• Impetigo

• Behçet’s syndrome

• Coxsackievirus infection

• Stevens-Johnson syndrome

• Herpangina

• Aphthous stomatitis

• Varicella

• Herpes zoster

Herpes Zoster

• Rash: herpes simplex and other viral infections

• Pain from herpes zoster: may be confused with acute myocardial infarction (MI), pulmonary embolism, pleuritis, pericarditis, renal colic

Hiatal Hernia

• Peptic ulcer disease

• Unstable angina

• Esophagitis (e.g., Candida, herpes, nonsteroidal anti-inflammatory drugs [NSAIDs])

• Esophageal spasm

• Barrett’s esophagus

• Schatzki’s ring

• Achalasia

• Zenker’s diverticulum

• Esophageal cancer

Hiccups ²²

TRANSIENT HICCUPS

• Sudden excitement, emotion

• Gastric distention

• Esophageal obstruction

• Alcohol ingestion

• Sudden change in temperature

PERSISTENT OR CHRONIC HICCUPS

• Toxic/metabolic: uremia, DM, hyperventilation, hypocalcemia, hypokalemia, hyponatremia, gout, fever

• Drugs: benzodiazepines, steroids, methyldopa, barbiturates

• Surgery/general anesthesia

• Thoracic/diaphragmatic disorders: pneumonia, lung cancer, asthma, pleuritis, pericarditis, myocardial infarction (MI), aortic aneurysm, esophagitis, esophageal obstruction, diaphragmatic hernia or irritation

• Abdominal disorders: gastric ulcer or cancer, hepatobiliary or pancreatic disease, inflammatory bowel disease (IBD), bowel obstruction, intra-abdominal or subphrenic abscess, prostatic infection or cancer

• CNS disorders: traumatic, infectious, vascular, structural

• Ear, nose, and throat disorders: pharyngitis, laryngitis, tumor, irritation of auditory canal

• Psychogenic disorders

• Idiopathic disorders

Hidradenitis Suppurativa

• Folliculitis and other follicular pyodermas, furuncles, pilonidal cysts

• Granuloma inguinale

• Crohn’s disease (perianal and vulvar manifestations)

• Bartholin’s cyst infection

• Actinomycosis

• Lymphogranuloma venereum

• Furuncle

• Lymphangitis

• Cat-scratch disease

• Tularemia

• Erysipelas

• Ulcerative colitis

Hip Pain, Children ²⁷

TRAUMA

• Hip or pelvis fractures

• Overuse injuries

INFECTION

• Septic arthritis

• Osteomyelitis

INFLAMMATION

• Transient synovitis

• Juvenile rheumatoid arthritis (JRA)

• Rheumatic fever

NEOPLASM

• Leukemia

• Osteogenic or Ewing’s sarcoma

• Metastatic disease

HEMATOLOGIC DISORDERS

• Hemophilia

• Sickle cell anemia

MISCELLANEOUS

• Legg-Calvé-Perthes disease

• Slipped capital femoral epiphysis

Hip Pain, in Different Age Groups ⁸

Common causes of hip pain in different age groups:

EARLY ADULTHOOD (18–30 YEARS)

OLD AGE (50 YEARS)

Intra-articular

• Osteoarthritis

• Inflammatory arthritis

Referred

• Abdominal

• Lumbar spine

Hirsutism

• Idiopathic: familial, possibly increased sensitivity to androgens

• Menopause

• Polycystic ovary syndrome

• Drugs: androgens, anabolic steroids, methyltestosterone, minoxidil, diazoxide, phenytoin, glucocorticoids, cyclosporine

• Congenital adrenal hyperplasia

• Adrenal virilizing tumor

• Ovarian virilizing tumor: arrhenoblastoma, hilar cell tumor

• Pituitary adenoma

• Cushing’s syndrome

• Hypothyroidism (congenital and juvenile)

• Acromegaly

• Testicular feminization

Histoplasmosis

• Acute pulmonary histoplasmosis: Mycobacterium tuberculosis; community-acquired pneumonias caused by Mycoplasma and Chlamydia; other fungal diseases, such as Blastomyces dermatitidis and Coccidioides immitis

• Chronic cavitary pulmonary histoplasmosis: M. tuberculosis

• Yeast forms of histoplasmosis on tissue section: cysts of Pneumocystis jiroveci, which tend to be larger, are extracellular, and do not display budding

• Intracellular parasites of Leishmania and Toxoplasma species: distinguishable by inability to take up methenamine silver

• Histoplasmomas: true neoplasms

Histrionic Personality

• Borderline personality disorder

• Antisocial personality disorder

• Narcissistic personality disorder

• Dependent personality disorder

• Personality change secondary to general medical condition

• Symptoms may develop in association with chronic substance abuse.

HIV Infection, Anorectal Lesions ²⁷

COMMON CONDITIONS

• Anal fissure

• Abscess and fistula

• Hemorrhoids

• Pruritus ani

• Pilonidal disease

COMMON STDS

• Condylomata acuminata

ATYPICAL CONDITIONS

• Infectious: TB, cytomegalovirus (CMV), actinomycosis, cryptococcosis

• Neoplastic: lymphoma, Kaposi’s sarcoma, squamous cell carcinoma

• Other: idiopathic and ulcer

HIV Infection, Chest Radiographic Abnormalities ²⁷

DIFFUSE INTERSTITIAL INFILTRATION

• Pneumocystis jiroveci

• Cytomegalovirus

• Mycobacterium tuberculosis

• Mycobacterium avium complex

• Histoplasmosis

• Coccidioidomycosis

• Lymphoid interstitial pneumonitis

FOCAL CONSOLIDATION

• Bacterial pneumonia

• Mycoplasma pneumoniae

• P. jiroveci

• M. tuberculosis

• M. avium complex

NODULAR LESIONS

CAVITARY LESIONS

• P. jiroveci

• M. tuberculosis

• Bacterial infection

PLEURAL EFFUSION

• Kaposi’s sarcoma

• Small effusion may be associated with any infection.

ADENOPATHY

PNEUMOTHORAX

• Kaposi’s sarcoma

HIV Infection, Cognitive Impairment ²⁶

EARLY TO MIDSTAGE HIV DISEASE

• Depression

• Alcohol and substance abuse

• Medication-induced cognitive impairment

• Metabolic encephalopathies

• HIV-related cognitive impairment

HIV Infection, Cutaneous Manifestations ²²

BACTERIAL INFECTION

• Bacillary angiomatosis: numerous angiomatous nodules associated with fever, chills, weight loss

• Staphylococcus aureus: folliculitis, ecthyma, impetigo, bullous impetigo, furuncles, carbuncles

• Syphilis: may occur in different forms (primary, secondary, tertiary); chancre may become painful because of secondary infection

FUNGAL INFECTION

• Candidiasis: mucous membranes (oral, vulvovaginal), less commonly Candida intertrigo or paronychia

• Cryptococcoses: papules or nodules that strongly resemble molluscum contagiosum; other forms include pustules, purpuric papules, and vegetating plaques

• Seborrheic dermatitis: scaling and erythema in the hair-bearing areas (eyebrows, scalp, chest, and pubic area)

ARTHROPOD INFESTATIONS

• Scabies: pruritus with or without rash, usually generalized but can be limited to a single digit

VIRAL INFECTION

• Herpes simplex: vesicular lesion in clusters; perianal, genital, orofacial, or digital; can be disseminated

• Herpes zoster: painful dermatomal vesicles that may ulcerate or disseminate

• HIV: discrete erythematous macules and papules on the upper trunk, palms, and soles are the most characteristic cutaneous finding of acute HIV infection.

• Human papillomavirus: genital warts (may become unusually extensive)

• Kaposi’s sarcoma (herpesvirus): erythematous macules or papules; enlarge at varying rates; violaceous nodules or plaques; occasionally painful

• Molluscum contagiosum: discrete umbilicated papules commonly on the face, neck, and intertriginous sites (axilla, groin, or buttocks)

NONINFECTIOUS

• Drug reactions: more frequent and severe in patients with HIV infection

• Nutritional deficiencies: mainly seen in children and patients with chronic diarrhea; diffuse skin manifestations, depending on the deficiency

• Psoriasis: scaly lesions; diffuse or localized; can be associated with arthritis

• Vasculitis: palpable purpuric eruption (can resemble septic emboli)

HIV Infection, Esophageal Disease

• Candida infection

• Cytomegalovirus (CMV) infection

• Aphthous ulcer

• Herpes simplex

HIV Infection, Hepatic Disease ²⁶

MYCOBACTERIA

• Mycobacterium avium complex

• Mycobacterium tuberculosis

FUNGI

• Histoplasma capsulatum

• Cryptococcus neoformans

• Coccidioides immitis

• Candida albicans

• Pneumocystis jiroveci

• Penicillium marneffei

PROTOZOA

• Toxoplasma gondii

• Cryptosporidium parvum

• Microsporida spp.

• Schistosoma

BACTERIA

• Bartonella henselae (peliosis hepatis)

MALIGNANCY

• Kaposi’s sarcoma (human herpesvirus 8 [HHV-8])

• Non-Hodgkin’s lymphoma

• Hepatocellular carcinoma

MEDICATIONS

• Zidovudine

• Didanosine

• Ritonavir

• Other HIV-1 protease inhibitors

• Fluconazole

• Macrolide antibiotics

• Isoniazid

• Rifampin

• Trimethoprim-sulfamethoxazole

HIV Infection, Lower GI Tract Disease ²⁶

CAUSES OF PROCTITIS

Bacteria

• Chlamydia trachomatis

• Neisseria gonorrhoeae

• Treponema pallidum

Viruses

• Herpes simplex

• CMV

HIV Infection, Ocular Manifestations ³⁷

EYELIDS

• Molluscum contagiosum

• Kaposi’s sarcoma

CORNEA/CONJUNCTIVA

• Keratoconjunctivitis sicca

• Bacterial/fungal ulcerative keratitis

• Herpes simplex

• Herpes zoster ophthalmicus

• Conjunctival microvasculopathy

• Kaposi’s sarcoma

DRUGS ASSOCIATED WITH OCULAR TOXICITY

• Rifabutin

• Didanosine

NEURO-OPHTHALMIC

• Disc edema

• Primary or secondary optic neuropathy

• Cranial nerve palsies

ORBITAL

• Lymphoma

• Infection

• Pseudotumor

HIV Infection, Pulmonary Disease ²⁶

MYCOBACTERIAL

• Mycobacterium tuberculosis

• Mycobacterium kansasii

• Mycobacterium avium complex

• Other nontuberculous mycobacteria

FUNGAL

• Pneumocystis jiroveci

• Cryptococcus neoformans

• Histoplasma capsulatum

• Coccidioides immitis

• Aspergillus species

• Bacillus dermatitidis

• Penicillium marneffei

VIRAL

• Cytomegalovirus (CMV)

• Herpes simplex virus

• Adenovirus

• Respiratory syncytial virus

• Influenza viruses

• Parainfluenza virus

Hoarseness

• Allergic rhinitis

• Infections (laryngitis, epiglottitis, tracheitis, croup)

• Vocal cord polyps

• Voice strain

• Irritants (tobacco smoke)

• Vocal cord trauma (intubation, surgery)

• Neoplastic involvement of vocal cord (primary or metastatic)

• Neurologic abnormalities (multiple sclerosis [MS], amyotrophic lateral sclerosis [ALS], parkinsonism)

• Endocrine abnormalities (puberty, menopause, hypothyroidism)

• Other (laryngeal webs or cysts, psychogenic, muscle tension abnormalities)

Hodgkin’s Disease

• Non-Hodgkin’s lymphoma

• Sarcoidosis

• Infections (e.g., cytomegalovirus [CMV], Epstein-Barr virus, toxoplasma, HIV)

• Drug reaction

• Cat-scratch disease

• Metastatic neoplasm

• Chronic lymphocytic leukemia (CLL)

Hookworm

• Strongyloidiasis

• Ascariasis

• Other causes of iron deficiency anemia and malabsorption

Hordeolum

• Eyelid abscess

• Chalazion

• Allergy or contact dermatitis with conjunctival edema

• Acute dacryocystitis

• Herpes simplex infection

• Cellulitis of the eyelid

Horner’s Syndrome

CAUSES OF ANISOCORIA (UNEQUAL PUPILS)

• Normal variant

• Mydriatic use

• Prosthetic eye

• Unilateral cataract

• Iritis

Hot Flashes

• Menopause

• Anxiety disorder

• Idiopathic flushing

• Lymphoma (night sweats)

• Hyperthyroidism

• Carcinoid syndrome

• Medications (e.g., niacin)

Human Granulocytic Ehrlichiosis

• Human monocytic ehrlichiosis (HME)

• Caused by Ehrlichia chaffeensis (vector: tick Amblyomma americanum, possibly Dermacentor variabilis)

• Rash more common, sometimes petechial

• Morulae in monocytes

• Rocky Mountain spotted fever, Colorado tick fever, Q fever, relapsing fever

• Legionnaires’ disease

• Tularemia

• Typhoid fever, paratyphoid fever

• Brucellosis

• Viral hepatitis

• Enteroviral infections

• Meningococcemia

• Influenza

• Adenovirus pneumonia

Human Immunodeficiency Virus Infection

• Acute infection: mononucleosis or other respiratory viral infections

• Late symptoms: similar to those produced by other wasting illnesses, such as neoplasms, TB, disseminated fungal infection, malabsorption, or depression

• HIV-related encephalopathy: confused with Alzheimer’s disease or other causes of chronic dementia; myelopathy and neuropathy possibly resembling other demyelinating diseases, such as multiple sclerosis (MS)

Huntington’s Disease

• Drug-induced chorea: dopamine, stimulants, anticonvulsants, antidepressants, and oral contraceptives have all been known to cause chorea.

• Sydenham’s chorea: decreased incidence with decline of rheumatic fever

• Benign hereditary chorea: autosomal dominant with onset in childhood. There is no progression of symptoms and no associated dementia or behavioral problems.

• Senile chorea

• Wilson’s disease: autosomal recessive; tremor, dysarthria, and dystonia are more common presentations than chorea. Of patients with neurologic manifestations, 95% will have Kayser-Fleischer rings.

• Neuroacanthocytosis: autosomal recessive; chorea, dystonia, tics, and orolingual dyskinesias that can result in self-mutilation; must look for acanthocytes in peripheral smear

• Dentatorubropallidoluysian atrophy: autosomal dominant, triplet repeat disease; presentation is variable and includes chorea, myoclonus, dementia, and ataxia; more common in Japan; can be confirmed by genetic testing

• Postinfectious

• Systemic lupus erythematosus (SLE): can be the presenting feature of lupus; occurs in only about 1% of individuals with lupus; pathophysiology unknown

• Chorea gravidarum: presents during first 4 to 5 months of pregnancy and resolves after delivery

• Paraneoplastic: seen most commonly in small cell lung cancer and lymphoma

Hydrocele

• Spermatocele

• Inguinoscrotal hernia

• Testicular tumor

• Varicocele

• Epididymitis

Hydrocephalus

• Head trauma

• Brain neoplasm (primary or metastatic)

• Spinal cord tumor

• Cerebellar infarction

• Exudative or granulomatous meningitis

• Cerebellar hemorrhage

• Subarachnoid hemorrhage

• Aqueductal stenosis

• Third ventricle colloid cyst

• Hindbrain malformation

• Viral encephalitis

• Metastases to leptomeninges

Hydrocephalus, Normal Pressure

• Alzheimer’s disease with extrapyramidal features

• Cognitive impairment in the setting of Parkinson’s disease or Parkinson’s plus syndromes

• Diffuse Lewy body disease

• Frontotemporal dementia

• Cervical spondylosis with cord compromise in setting of degenerative dementia

• Multifactorial gait disorder

• Multi-infarct dementia

Hydronephrosis

• Urinary stones

• Neoplastic disease

• Prostatic hypertrophy

• Neurologic disease

• Urinary reflux

• Urinary tract infection (UTI)

• Medication effects

• Trauma

• Congenital abnormality of urinary tract

Hyperaldosteronism

• Diuretic use

• Hypokalemia from vomiting, diarrhea

• Renovascular hypertension

• Other endocrine neoplasm (pheochromocytoma, deoxycorticosterone-producing tumor, renin-secreting tumor)

Hyperamylasemia

• Pancreatitis (acute or chronic)

• Macroamylasemia

• Salivary gland inflammation

• Mumps

• Pancreatic neoplasm

• Pancreatic abscess

• Pancreatic pseudocyst

• Perforated peptic ulcer

• Intestinal obstruction

• Intestinal infarction

• Acute cholecystitis

• Appendicitis

• Ruptured ectopic pregnancy

• Peritonitis

• Burns

• Diabetic ketoacidosis (DKA)

• Renal insufficiency

• Drugs (morphine)

• Carcinomatosis of lung, esophagus, ovary

• Acute ethanol ingestion

• Prostate tumors

• Post endoscopic retrograde cholangiopancreatography (ERCP)

• Bulimia, anorexia nervosa

Hyperbilirubinemia (Conjugated Bilirubin)

• Hepatocellular disease

• Biliary obstruction

• Drug-induced cholestasis

• Hereditary disorders (Dubin-Johnson syndrome, Rotor’s syndrome)

• Advanced neoplastic states

Hyperbilirubinemia, Total

• Liver disease (hepatitis, cirrhosis, cholangitis, neoplasm, biliary obstruction, infectious mononucleosis)

• Hereditary disorders (Gilbert’s disease, Dubin-Johnson syndrome)

• Drugs (steroids, diphenylhydantoin, phenothiazines, penicillin, erythromycin, clindamycin, captopril, amphotericin B, sulfonamides, azathioprine, isoniazid, 5-aminosalicylic acid, allopurinol, methyldopa, indomethacin, halothane, oral contraceptives, procainamide, tolbutamide, labetalol)

• Hemolysis

• Pulmonary embolism or infarct

• Hepatic congestion resulting from congestive heart failure (CHF)

Hyperbilirubinemia (Unconjugated Bilirubin)

• Hemolysis

• Liver disease (hepatitis, cirrhosis, neoplasm)

• Hepatic congestion caused by congestive heart failure (CHF)

• Hereditary disorders (Gilbert’s disease, Crigler-Najjar syndrome)

Hypercalcemia

• Malignant disease: increased bone resorption via osteoclast-activating factors, secretion of parathyroid hormone (PTH)–like substances, prostaglandin E₂, direct erosion by tumor cells, transforming growth factors, colony-stimulating activity

• Hypercalcemia is common in the following neoplasms:

• Solid tumors: breast, lung, pancreas, kidneys, ovary

• Hematologic cancers: myeloma, lymphosarcoma, adult T-cell lymphoma, Burkitt’s lymphoma

• Hyperparathyroidism: increased bone resorption, GI absorption, and renal absorption; etiology:

• Parathyroid hyperplasia, adenoma

• Hyperparathyroidism or renal failure with secondary hyperparathyroidism

• Granulomatous disorders: increased GI absorption (e.g., sarcoidosis)

• Paget’s disease: increased bone resorption, seen only during periods of immobilization

• Vitamin D intoxication, milk-alkali syndrome: increased GI absorption

• Thiazides: increased renal absorption

• Other causes: familial hypocalciuric hypercalcemia, thyrotoxicosis, adrenal insufficiency, prolonged immobilization, vitamin A intoxication, recovery from acute renal failure, lithium administration, pheochromocytoma, disseminated systemic lupus erythematosus (SLE)

Hypercalcemia, Malignancy Induced

• Lung carcinoma: 6% frequency, 35% of hypercalcemic cases

• Breast carcinoma: 10% frequency, 25% of hypercalcemic cases

• Multiple myeloma: 33% frequency, 10% of hypercalcemic cases

• Lymphoma: 4% of hypercalcemic cases

• Genitourinary cancer: 6% of hypercalcemic cases

Hypercapnia, Persistent ³⁷

• Hypercapnia with normal lungs: CNS disturbances (cerebrovascular accident [CVA], parkinsonism, encephalitis), metabolic alkalosis, myxedema, primary alveolar hypoventilation, spinal cord lesions

• Diseases of the chest wall (e.g., kyphoscoliosis, ankylosing spondylitis)

• Neuromuscular disorders (e.g., myasthenia gravis, Guillain-Barré syndrome, amyotrophic lateral sclerosis [ALS], muscular dystrophy, poliomyelitis)

• Chronic obstructive pulmonary disease (COPD)

Hyperchloremia

• Dehydration

• Sodium loss > chloride loss

• Respiratory alkalosis

• Excessive infusion of normal saline solution

• Cystic fibrosis (CF)

• Hyperparathyroidism

• Renal tubular disease

• Metabolic acidosis

• Prolonged diarrhea

• Acetazolamide administration

• Diabetes insipidus (DI)

• Ureterosigmoidostomy

Hypercholesterolemia

• Diet high in cholesterol and saturated fat

• Primary hypercholesterolemia

• Uncontrolled diabetes mellitus

• Nephrotic syndrome

• Hypothyroidism

• Primary biliary cirrhosis

• Third trimester of pregnancy

• Drugs (steroids, phenothiazines, oral contraceptives)

• Biliary obstruction

Hypercoagulable State, Acquired

ANTIPHOSPHOLIPID ANTIBODY SYNDROME (APS)

• Most common cause of acquired thrombophilia

• Can present as arterial or venous thrombosis, recurrent pregnancy loss, and adverse pregnancy outcomes

• Thromboembolic events occur in up to 30% of population; high risk of recurrent thrombosis (up to 70% reported).

• See Antiphospholipid Antibody Syndrome for more information.

HYPERHOMOCYSTEINEMIA

• Can be inherited (most commonly an autosomal recessive mutation in methylene tetrahydrofolate reductase gene) but more frequently acquired; folate, vitamin B₆, or vitamin B₁₂ deficiency accounts for two thirds of cases. Other acquired causes include renal disease, hypothyroidism, malignant disease, smoking, and certain medications.

• May be associated with venous thromboembolism (VTE), atherosclerotic disease (cardiovascular, cerebrovascular, and peripheral vascular), and possibly adverse pregnancy outcomes

Hypercoagulable State, Associated Disorders ²¹

• Systemic lupus erythematosus in association with the presence of a lupus anticoagulant or antiphospholipid antibodies

• Malignant neoplasm

• Disease related: includes migratory superficial thrombophlebitis (Trousseau’s syndrome), nonbacterial thrombotic endocarditis, thrombosis associated with chronic DIC, thrombotic microangiopathy

• Treatment related: associated with the administration of various chemotherapeutic agents (asparaginase, mitomycin, some adjuvant chemotherapeutic agents for treatment of breast cancer, thalidomide or lenalidomide in conjunction with high doses of dexamethasone)

• Infusion of prothrombin complex concentrates

• Nephrotic syndrome

• Heparin-induced thrombocytopenia

• Myeloproliferative disorders

• Paroxysmal nocturnal hemoglobinuria

Hypercoagulable State, Inherited

FACTOR V LEIDEN (FVL) MUTATION

• Autosomal dominant mutation with low penetrance

• Causes activated protein C resistance (APCR); 90% of APCR is caused by FVL mutation

• Most common inherited thrombophilia; accounts for 40% to 50% of cases

• OC use in heterozygous carriers is associated with an 8-fold increased risk of VTE compared with noncarriers and a 35-fold increased risk of VTE compared with noncarriers not using OCs.

• May be associated with cardiovascular disease in select high-risk subgroups

PROTHROMBIN G20210A MUTATION

• Autosomal dominant mutation with low penetrance

• OC use in heterozygous carriers is associated with a 16-fold increased risk of VTE compared with noncarriers not using OCs.

• May be associated with cardiovascular disease in select high-risk subgroups and young patients with ischemic stroke

PROTEIN C, PROTEIN S, ANTITHROMBIN (AT) DEFICIENCY

• Autosomal dominant inheritance; many mutations identified for each of these conditions

• Decreased level or abnormal function

• First episode of thrombosis usually in young adults

Protein C and Protein S

• High risk of VTE

• Homozygous condition very rare; usually associated with lethal thrombosis in infancy

• Associated with warfarin-induced skin necrosis, which occurs secondary to depletion of vitamin K–dependent anticoagulant factors sooner than procoagulant factors in the first few days of therapy

AT Deficiency

• Most thrombogenic of the inherited thrombophilias; 50% lifetime risk of thrombosis

• Homozygous condition very rare, probably not compatible with normal fetal development

• Arterial thrombosis can occur rarely

• Can cause heparin resistance

ELEVATED FACTOR VIII LEVEL

• May be an important risk factor for thrombosis in African American population

• Increased risk of recurrent thrombosis

• Genetic etiology suspected but not yet identified

• Other possible causes: dysfibrinogenemia, elevated thrombin-activatable fibrinolysis inhibitor, plasminogen deficiency, elevated factor IX and factor XI levels

Hypercortisolemia

• Ectopic adrenocorticotropic hormone (ACTH) production (e.g., small cell carcinoma of lung)

• Loss of normal diurnal variation

• Pregnancy

• Chronic renal failure

• Iatrogenic

• Stress

• Adrenal or pituitary hyperplasia or adenomas

Hyperemesis Gravidarum

Hypereosinophilia

• Allergy

• Parasitic infestations (trichinosis, aspergillosis, hydatidosis)

• Angioneurotic edema

• Drug reactions

• Warfarin sensitivity

• Collagen-vascular diseases

• Acute hypereosinophilic syndrome

• Eosinophilic nonallergic rhinitis

• Myeloproliferative disorders

• Hodgkin’s disease

• Radiation therapy

• Non-Hodgkin’s lymphoma

• L-Tryptophan ingestion

• Urticaria

• Pernicious anemia

• Pemphigus

• Inflammatory bowel disease (IBD)

• Bronchial asthma

Hypergastrinemia

• Decreased gastrin release inhibition from medications (proton pump inhibitors [PPIs], H₂ receptor antagonists), vagotomy

• Chronic renal failure

• Hypochlorhydria due to atrophic gastritis, gastric carcinoma, pernicious anemia

• Gastrinoma (Zollinger-Ellison syndrome)

• Pyloric obstruction

• Hyperplasia of antral G cells

• Rheumatoid arthritis (RA)

Hyperglycemia

• Diabetes mellitus (DM)

• Drugs (glucocorticoids, diuretics [thiazides, loop diuretics])

• Impaired glucose tolerance

• Stress

• Infections

• Myocardial infarction (MI)

• Cerebrovascular accident (CVA)

Hyperhidrosis ⁴

MEDULLARY

• Physiologic gustatory sweating

• Encephalitis

• Granulosis rubra nasi

• Syringomyelia

• Thoracic sympathetic trunk injury

SPINAL

• Cord transection

• Syringomyelia

CHANGES IN BLOOD FLOW

• Arteriovenous fistula

• Klippel-Trénaunay syndrome

• Glomus tumor

• Blue rubber bleb nevus syndrome

Hyperimmunoglobulinemia

• IgA: lymphoproliferative disorders, Berger’s nephropathy, chronic infections, autoimmune disorders, liver disease

• IgE: allergic disorders, parasitic infections, immunologic disorders, IgE myeloma, AIDS, pemphigoid

• IgG: chronic granulomatous infections, infectious diseases, inflammation, myeloma, liver disease

• IgM: primary biliary cirrhosis, infectious diseases (brucellosis, malaria), Waldenström’s macroglobulinemia, liver disease

Hyperkalemia

PSEUDOHYPERKALEMIA

• Hemolyzed specimen

• Severe thrombocytosis (platelet count >106 mL)

• Severe leukocytosis (white blood cell count >105 mL)

• Fist clenching during phlebotomy

EXCESSIVE POTASSIUM INTAKE (OFTEN IN SETTING OF IMPAIRED EXCRETION)

• Potassium replacement therapy

• High-potassium diet

• Salt substitutes with potassium

• Potassium salts of antibiotics

Hyperkinetic Movement Disorders ³¹

• Chorea, choreoathetosis: drug induced, Huntington’s chorea, Sydenham’s chorea

• Tardive dyskinesia (e.g., phenothiazines)

• Hemiballismus (lacunar cerebrovascular accident [CVA] near subthalamic nuclei in basal ganglia, metastatic lesions, toxoplasmosis [in AIDS])

• Dystonia (idiopathic, familial, drug induced [prochlorperazine, metoclopramide]), Wilson’s disease

• Liver failure

• Thyrotoxicosis

• Systemic lupus erythematosus (SLE), polycythemia

Hyperlipoproteinemia, Primary

Hypermagnesemia

• Renal failure (decreased glomerular filtration rate [GFR])

• Decreased renal excretion secondary to salt depletion

• Abuse of antacids and laxatives containing magnesium in patients with renal insufficiency

• Endocrinopathies (deficiency of mineralocorticoid or thyroid hormone)

• Increased tissue breakdown (rhabdomyolysis)

• Redistribution: acute diabetic ketoacidosis (DKA), pheochromocytoma

• Other: lithium, volume depletion, familial hypocalciuric hypercalcemia

Hypernatremia

ISOVOLEMIC HYPERNATREMIA

Decreased total body water, normal total body sodium and extracellular fluid

• Diabetes insipidus (neurogenic and nephrogenic)

• Skin loss (hyperemia), iatrogenic, reset osmostat

HYPERVOLEMIC HYPERNATREMIA

Increased total body water, markedly increased total body sodium and extracellular fluid

• Iatrogenic (administration of hypernatremic solutions)

• Mineralocorticoid excess (Conn’s syndrome, Cushing’s syndrome)

• Salt ingestion

HYPOVOLEMIC HYPERNATREMIA

Loss of H₂O and Na⁺ (H₂O Loss > Na⁺)

• Renal losses (e.g., diuretics, glycosuria)

• GI, respiratory, skin losses

• Adrenal deficiencies

Hyperosmolality, Serum

• Dehydration

• Hypernatremia

• Diabetes insipidus (DI)

• Uremia

• Hyperglycemia

• Mannitol therapy

• Ingestion of toxins (ethylene glycol, methanol, ethanol), hypercalcemia, diuretics

Hyperosmolality, Urine

• Syndrome of inappropriate antidiuretic hormone (SIADH)

• Dehydration

• Glycosuria

• Adrenal insufficiency

• High-protein diet

Hyperparathyroidism

OTHER CAUSES OF HYPERCALCEMIA

• Malignant disease: neoplasms of breast, lung, kidney, ovary, pancreas; myeloma, lymphoma

• Granulomatous disorders (e.g., sarcoidosis)

• Paget’s disease

• Vitamin D intoxication, milk-alkali syndrome

• Thiazide diuretics

• Other: familial hypocalciuric hypercalcemia, thyrotoxicosis, adrenal insufficiency, prolonged immobilization, vitamin A intoxication, recovery from acute renal failure, lithium administration, pheochromocytoma, disseminated systemic lupus erythematosus (SLE)

Hyperphosphatemia

• Excessive phosphate administration

• Excessive oral intake or IV administration

• Laxatives containing phosphate (phosphate tablets, phosphate enemas)

• Decreased renal phosphate excretion

• Acute or chronic renal failure

• Hypoparathyroidism or pseudohypoparathyroidism

• Acromegaly, thyrotoxicosis

• Bisphosphonate therapy

• Tumor calcinosis

• Sickle cell anemia

• Transcellular shift out of cells

• Chemotherapy of lymphoma or leukemia, tumor lysis syndrome, hemolysis

• Acidosis

• Rhabdomyolysis, malignant hyperthermia

• Artifact: in vitro hemolysis

• Pseudohyperphosphatemia: hyperlipidemia, paraproteinemia, hyperbilirubinemia

Hyperpigmentation ⁶

• Addison’s disease

• Arsenic ingestion

• Adrenocorticotropic hormone (ACTH)– or melanocyte-stimulating hormone (MSH)–producing tumors (e.g., small cell carcinoma of the lung)

• Drug induced (e.g., antimalarials, some cytotoxic agents)

• Hemochromatosis (“bronze” diabetes)

• Malabsorption syndrome (Whipple’s disease and celiac sprue)

• Melanoma

• Melanotropic hormone injection

• Pheochromocytoma

• Porphyrias (porphyria cutanea tarda and variegate porphyria)

• Pregnancy

• Progressive systemic sclerosis and related conditions

• Psoralen plus ultraviolet A (PUVA) therapy (psoralen administration) for psoriasis and vitiligo

Hyperprolactinemia

• Prolactinomas (level >200 highly suggestive)

• Drugs (phenothiazines, cimetidine, tricyclic antidepressants, metoclopramide, estrogens, antihypertensives [methyldopa, verapamil], haloperidol)

Hyperproteinemia

• Dehydration

• Sarcoidosis

• Collagen vascular diseases

• Multiple myeloma

• Waldenström’s macroglobulinemia

Hypersensitivity Pneumonitis

• Aspiration pneumonia

• Recurrent pneumonia

• Bronchiolitis obliterans organizing pneumonia (BOOP)

• Sarcoidosis

• Churg-Strauss syndrome

• Wegener’s granulomatosis

Hypersplenism

• Splenic congestion: cirrhosis; congestive heart failure (CHF); portal, splenic, or hepatic vein thrombosis

• Hematologic causes: hemolytic anemia, sickle cell anemia, thalassemia, spherocytosis, elliptocytosis

• Infections: viral (hepatitis, infectious mononucleosis, cytomegalovirus [CMV], HIV), bacterial (endocarditis, TB, brucellosis, Lyme), parasitic (malaria, leishmaniasis, schistosomiasis, toxoplasmosis), fungal

• Malignant disease: leukemia, lymphoma, polycythemia vera, myeloproliferative diseases, metastatic tumors

• Inflammatory diseases: Felty’s syndrome, systemic lupus erythematosus (SLE), sarcoidosis

• Infiltrative diseases: amyloidosis, Gaucher’s disease, Niemann-Pick disease, glycogen storage disease

Hyperthyroidism

• Anxiety disorder

• Pheochromocytoma

• Metastatic neoplasm

• Diabetes mellitus (DM)

• Premenopausal state

Hypertrichosis ⁷

DRUGS

SYSTEMIC ILLNESS

IDIOPATHIC

Hypertriglyceridemia

• Hyperlipoproteinemias (types I, IIb, III, IV, V)

• Diet high in saturated fats

• Poorly controlled diabetes mellitus (DM)

• Sedentary lifestyle

• Glycogen storage disease

Hypertrophic Osteoarthropathy

• Rheumatoid arthritis (RA)

• Osteomyelitis

Hyperuricemia

• Hereditary enzyme deficiency (hypoxanthine-guanine phosphoribosyltransferase)

• Renal failure

• Gout

• Excessive cell lysis (chemotherapeutic agents, radiation therapy, leukemia, lymphoma, hemolytic anemia)

• Acidosis

• Myeloproliferative disorders

• Diet high in purines or protein

• Drugs (diuretics, low doses of aspirin, ethambutol, nicotinic acid)

• Lead poisoning

• Hypothyroidism

Hyperventilation, Persistent ³⁷

• Fibrotic lung disease

• Metabolic acidosis (e.g., diabetes, uremia)

• CNS disorders (midbrain and pontine lesions)

• Hepatic coma

• Salicylate intoxication

• Fever

• Sepsis

• Psychogenic (e.g., anxiety)

Hyperviscosity, Serum

• Monoclonal gammopathies (Waldenström’s macroglobulinemia, multiple myeloma)

• Hyperfibrinogenemia

• Systemic lupus erythematosus (SLE)

• Rheumatoid arthritis (RA)

• Polycythemia

• Leukemia

Hypoalbuminemia

• Liver disease

• Nephrotic syndrome

• Poor nutritional status

• Rapid IV hydration

• Protein-losing enteropathies (inflammatory bowel disease [IBD])

• Severe burns

• Neoplasia

• Chronic inflammatory diseases

• Pregnancy

• Prolonged immobilization

• Lymphomas

• Hypervitaminosis A

• Chronic glomerulonephritis

Hypoaldosteronism

Pseudohypoaldosteronism: renal unresponsiveness to aldosterone. In this condition, both renin and aldosterone levels are elevated. Pseudohypoaldosteronism can be caused by medications (spironolactone), chronic interstitial nephritis, systemic disorders (systemic lupus erythematosus, amyloidosis), or primary mineralocorticoid resistance.

Hypocalcemia

• Renal insufficiency: hypocalcemia caused by

• Increased calcium deposits in bone and soft tissue secondary to increased serum PO₄⁻³ level

• Decreased production of 1,25-dihydroxyvitamin D

• Excessive loss of 25-OHD (nephrotic syndrome)

• Hypoalbuminemia: each decrease in serum albumin (g/L) will decrease serum calcium by 0.8 mg/dL but will not change free (ionized) calcium.

• Vitamin D deficiency

• Malabsorption (most common cause)

• Inadequate intake

• Decreased production of 1,25-dihydroxyvitamin D (vitamin D–dependent rickets, renal failure)

• Decreased production of 25-OHD (parenchymal liver disease)

• Accelerated 25-OHD catabolism (phenytoin, phenobarbital)

• End-organ resistance to 1,25-dihydroxyvitamin D

• Hypomagnesemia: hypocalcemia caused by

• Decreased parathyroid hormone (PTH) secretion

• Inhibition of PTH effect on bone

• Pancreatitis, hyperphosphatemia, osteoblastic metastases: hypocalcemia is secondary to increased calcium deposits (bone, abdomen).

• Pseudohypoparathyroidism: autosomal recessive disorder characterized by short stature, shortening of metacarpal bones, obesity, and mental retardation; the hypocalcemia is secondary to congenital end-organ resistance to PTH.

• Idiopathic hypoparathyroidism, surgical removal of parathyroids (e.g., neck surgery)

• “Hungry bones syndrome”: rapid transfer of calcium from plasma into bones after removal of a parathyroid tumor

• Sepsis

• Massive blood transfusion (as a result of ethylenediaminetetraacetic acid [EDTA] in blood)

Hypocapnia

• Hyperventilation

• Pneumonia, pneumonitis

• Fever, sepsis

• Medications (salicylates, β-adrenergic agonists, progesterone, methylxanthines)

• Pulmonary disease (asthma, interstitial fibrosis)

• Congestive heart failure (CHF)

• Pregnancy

• Pain

• CNS lesions

Hypochloremia

• Vomiting

• Gastric suction

• Primary aldosteronism

• Congestive heart failure (CHF)

• Syndrome of inappropriate antidiuretic hormone (SIADH)

• Addison’s disease

• Salt-losing nephritis

• Continuous infusion of D₅W

• Thiazide diuretic administration

• Diaphoresis

• Diarrhea

• Burns

• Diabetic ketoacidosis (DKA)

Hypochondriasis

• Underlying medical condition, such as multiple sclerosis, hypothyroidism, or systemic lupus erythematosus (SLE)

• Somatization disorder

• Body dysmorphic disorder (restricted to a circumscribed concern about appearance)

• Factitious disorder or malingering

• Generalized anxiety disorder with health concerns as one worry among many others

• Major depressive disorder with health concerns occurring only during depressive episodes

• Psychosis, such as may occur with depression or schizophrenia

Hypogonadism

HYPERGONADOTROPIC HYPOGONADISM

• Hormone resistance (androgen, luteinizing hormone [LH] insensitivity)

• Gonadal defects (e.g., Klinefelter’s syndrome, myotonic dystrophy)

• Drug induced (e.g., spironolactone, cytotoxins)

• Alcoholism, radiation induced

• Mumps orchitis

• Anatomic defects, castration

HYPOGONADOTROPIC HYPOGONADISM

• Pituitary lesions (neoplasms, granulomas, infarction, hemochromatosis, vasculitis)

• Drug induced (e.g., glucocorticoids)

• Hyperprolactinemia

• Genetic disorders (Laurence-Moon-Biedl syndrome, Prader-Willi syndrome)

• Delayed puberty

• Other: chronic disease, nutritional deficiency, Kallmann’s syndrome, idiopathic isolated LH or follicle-stimulating hormone (FSH) deficiency

Hypoimmunoglobulinemia

• IgA: nephrotic syndrome, protein-losing enteropathy, congenital deficiency, lymphocytic leukemia, ataxia-telangiectasia, chronic sinopulmonary disease

• IgE: hypogammaglobulinemia, neoplasm (breast, bronchial, cervical), ataxia-telangiectasia

• IgG: congenital or acquired deficiency, lymphocytic leukemia, phenytoin, methylprednisolone, nephrotic syndrome, protein-losing enteropathy

• IgM: congenital deficiency, lymphocytic leukemia, nephrotic syndrome

Hypokalemia

• Cellular shift (redistribution) and undetermined mechanisms

• Alkalosis (each 0.1 increase in pH decreases serum potassium by 0.4 to 0.6 mEq/L)

• Insulin administration

• Vitamin B₁₂ therapy for megaloblastic anemias, acute leukemias

• Hypokalemic periodic paralysis: rare familial disorder manifested by recurrent attacks of flaccid paralysis and hypokalemia

• β-Adrenergic agonists (e.g., terbutaline), decongestants, bronchodilators, theophylline, caffeine

• Barium poisoning, toluene intoxication, verapamil intoxication, chloroquine intoxication

• Correction of digoxin intoxication with digoxin antibody fragments (Digibind)

• Increased renal excretion secondary to medications: diuretics, including carbonic anhydrase inhibitors (e.g., acetazolamide); amphotericin B; high-dose sodium penicillin, nafcillin, ampicillin, or carbenicillin; cisplatin; aminoglycosides, corticosteroids, mineralocorticoids, foscarnet sodium

• Renal tubular acidosis (RTA): distal (type 1) or proximal (type 2)

• Diabetic ketoacidosis (DKA), ureteroenterostomy

• Magnesium deficiency

• Postobstruction diuresis, diuretic phase of tyrosinase-negative oculocutaneous albinism (ATN)

• Osmotic diuresis (e.g., mannitol)

• Bartter’s syndrome: hyperplasia of juxtaglomerular cells leading to increased renin and aldosterone, metabolic alkalosis, hypokalemia, muscle weakness, and tetany (seen in young adults)

• Increased mineralocorticoid activity (primary or secondary aldosteronism), Cushing’s syndrome

• Chronic metabolic alkalosis from loss of gastric fluid (increased renal potassium secretion)

• GI loss: vomiting, nasogastric suction, diarrhea, laxative abuse, villous adenoma, fistulas

• Inadequate dietary intake (e.g., anorexia nervosa)

• Cutaneous loss (excessive sweating)

• High dietary sodium intake, excessive use of licorice

Hypomagnesemia

GI AND NUTRITIONAL

• Defective GI absorption (malabsorption)

• Inadequate dietary intake (e.g., alcoholics)

• Parenteral therapy without magnesium

• Chronic diarrhea, villous adenoma, prolonged nasogastric suction, fistulas (small bowel, biliary)

Hyponatremia

HYPOTONIC HYPONATREMIA

Isovolemic Hyponatremia

• Syndrome of inappropriate antidiuretic hormone (SIADH)

• Water intoxication (e.g., schizophrenic patients, primary polydipsia, sodium-free irrigant solutions, multiple tap-water enemas, dilute infant formulas). These entities are rare and often associated with a deranged antidiuretic hormone (ADH) axis.

• Renal failure

• Reset osmostat (e.g., chronic active TB, carcinomatosis)

• Glucocorticoid deficiency (hypopituitarism)

• Hypothyroidism

• Thiazide diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), carbamazepine, amitriptyline, thioridazine, vincristine, cyclophosphamide, colchicine, tolbutamide, chlorpropamide, angiotensin-converting enzyme (ACE) inhibitors, clofibrate, oxytocin, selective serotonin reuptake inhibitors (SSRIs), amiodarone. With these medications, various drug-induced mechanisms are involved.

Hypovolemic Hyponatremia

• Renal losses (diuretics, partial urinary tract obstruction, salt-losing renal disease)

• Extrarenal losses: GI (vomiting, diarrhea), extensive burns, third spacing (peritonitis, pancreatitis)

• Adrenal insufficiency

Hypervolemic Hyponatremia

• Congestive heart failure (CHF)

• Nephrotic syndrome

• Cirrhosis

• Pregnancy

ISOTONIC HYPONATREMIA

Normal Serum Osmolality

• Pseudohyponatremia (increased serum lipids and serum proteins). Newer sodium assays eliminate this problem.

• Isotonic infusion (e.g., glucose, mannitol)

HYPERTONIC HYPONATREMIA

Increased Serum Osmolality

• Hyperglycemia: each 100 mg/dL increment in blood glucose level above normal decreases plasma sodium concentration by 1.6 mEq/L

• Hypertonic infusions (e.g., glucose, mannitol)

Hypo-osmolality, Serum

• Syndrome of inappropriate antidiuretic hormone (SIADH)

Hypo-osmolality, Urine

• Diabetes insipidus (DI)

• Excessive water intake

• IV hydration with D₅W

• Acute renal insufficiency

• Glomerulonephritis

Hypophosphatemia

• Decreased intake (prolonged starvation, hyperalimentation, or IV infusion without phosphate)

• Malabsorption

• Phosphate-binding antacids

• Renal loss: renal tubular acidosis (RTA), Fanconi’s syndrome, vitamin D–resistant rickets, tyrosinase-negative oculocutaneous albinism (ATN) (diuretic phase), hyperparathyroidism (primary or secondary), familial hypophosphatemia, hypokalemia, hypomagnesemia, acute volume expansion, glycosuria, idiopathic hypercalciuria, acetazolamide

• Transcellular shift into cells: alcohol withdrawal, diabetic ketoacidosis (DKA) (recovery phase), glucose-insulin or catecholamine infusion, anabolic steroids, total parenteral nutrition, theophylline overdose, severe hyperthermia, recovery from hypothermia, “hungry bones” syndrome

Hypopigmentation

• Vitiligo

• Tinea versicolor

• Atopic dermatitis

• Chemical leukoderma

• Idiopathic hypomelanosis

• Sarcoidosis

• Systemic lupus erythematosus (SLE)

• Scleroderma

• Oculocutaneous albinism

• Phenylketonuria (PKU)

• Nevoid hypopigmentation

Hypopituitarism

• Congenital: mutations in transcription factors produce multiple hormonal deficiencies. Mutations in genes produce single hormonal deficiency.

• Acquired: the result of destruction of pituitary cells caused by

• Pituitary apoplexy: hemorrhage or infarction of the pituitary gland. Predisposing factors include diabetes mellitus, anticoagulation therapy, head trauma, and radiation therapy. Sheehan’s syndrome: postpartum necrosis, a rare complication after pregnancy.

• Infiltrative disease, including sarcoidosis, hemochromatosis, histiocytosis X, Wegener’s granulomatosis, lymphocytic hypophysitis, and infection of the pituitary (tuberculosis, mycosis, syphilis)

• Primary empty sella syndrome: flattening of the pituitary gland caused by extension of the subarachnoid space and filling of cerebrospinal fluid into the sella turcica

• Pituitary tumors: classified by size (microadenomas, <10 mm; macroadenomas, >10 mm) and function. Prolactin-secreting tumors and nonfunctioning tumors account for the majority of pituitary adenomas.

• Suprasellar tumors: craniopharyngiomas are the most common.

Hypoproteinemia

Hypotension, Postural

• Antihypertensive medications (especially α-blockers, diuretics, angiotensin-converting enzyme [ACE] inhibitors)

• Volume depletion (hemorrhage, dehydration)

• Impaired cardiac output (constrictive pericarditis, aortic stenosis)

• Peripheral autonomic dysfunction (diabetes mellitus [DM], Guillain-Barré)

• Idiopathic orthostatic hypotension

• Central autonomic dysfunction (Shy-Drager syndrome)

• Peripheral venous disease

• Adrenal insufficiency

Hypothermia

• Cerebrovascular accident (CVA)

• Myxedema coma

• Drug intoxication

• Hypoglycemia

Hypothyroidism

• Depression

• Dementia from other causes

• Systemic disorders (e.g., nephrotic syndrome, congestive heart failure [CHF], amyloidosis)

• Chronic fatigue syndrome

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