Paget’s Disease of Bone

• Fibrous dysplasia

• Skeletal neoplasm (primary or metastatic)

• Osteomyelitis

• Hyperparathyroidism

• Vertebral hemangioma

Paget’s Disease of Breast

• Chronic dermatitis

• Florid papillomatosis of the nipple or nipple adenoma

• Basal cell carcinoma

• Contact dermatitis

• Seborrheic dermatitis

Pain, Midfoot

Pain, Plantar Aspect, Heel

• Plantar fasciitis

• Tarsal tunnel syndrome

• Neuroma

• Infection (osteomyelitis, septic arthritis, cellulitis) of foot

• Peripheral vascular insufficiency

• Plantar fascia rupture

Pain, Posterior Heel

• Achilles tendinitis

• Retrocalcaneal bursitis

• Retroachilles bursitis

• Infection (osteomyelitis, septic arthritis, cellulitis) of foot

• Peripheral vascular insufficiency

Palindromic Rheumatism ⁵

• Palindromic rheumatoid arthritis

• Essential palindromic rheumatism

• Crystal synovitis (gout, calcium pyrophosphate dihydrate [CPPD], pseudogout, calcific periarthritis)

• Lyme borreliosis, stages 2 and 3

• Sarcoidosis

• Whipple’s disease

• Acute rheumatic fever

• Reactive arthritis (rare)

Palmoplantar Hyperkeratosis

• Superficial skin infection

• Paraneoplastic acrokeratosis

Palpitations ³⁴

• Anxiety

• Electrolyte abnormalities (hypokalemia, hypomagnesemia)

• Exercise

• Hyperthyroidism

• Ischemic heart disease

• Ingestion of stimulant drugs (cocaine, amphetamines, caffeine)

• Medications (digoxin, β-blockers, calcium channel antagonists, hydralazines, diuretics, minoxidil)

• Hypoglycemia in type 1 diabetes mellitus (DM)

• Mitral valve prolapse

• Wolff-Parkinson-White (WPW) syndrome

• Sick sinus syndrome

Pancreatic Calcifications

• Chronic pancreatitis

• Hyperparathyroidism

• Metastatic neoplasm

• Pseudocyst

• Hereditary pancreatitis

• Cystadenoma

• Cystadenocarcinoma

• Cavernous lymphangioma

• Hemorrhage

• Acute pancreatitis (saponification)

Pancreatic Cancer (Exocrine)

• Common duct cholelithiasis

• Cholangiocarcinoma

• Common duct stricture

• Sclerosing cholangitis

• Primary biliary cirrhosis

• Drug-induced cholestasis (e.g., phenothiazines)

• Chronic hepatitis

• Sarcoidosis

• Other pancreatic tumors (islet cell tumor, cystadenocarcinoma, epidermoid carcinoma, sarcomas, lymphomas)

Pancreatitis, Acute

• Peptic ulcer disease (PUD)

• Acute cholangitis, biliary colic

• High intestinal obstruction

• Early acute appendicitis

• Mesenteric vascular obstruction

• Diabetic ketoacidosis (DKA)

• Pneumonia (basilar)

• Myocardial infarction (inferior wall)

• Renal colic

• Ruptured or dissecting aortic aneurysm

Pancreatitis, Chronic

• Pancreatic cancer

• Peptic ulcer disease (PUD)

• Cholelithiasis with biliary obstruction

• Malabsorption from other causes

• Recurrent acute pancreatitis

Pancytopenia ²¹

PANCYTOPENIA WITH HYPOCELLULAR BONE MARROW

• Acquired aplastic anemia

• Inherited aplastic anemia (Fanconi’s anemia and others)

• Some myelodysplasia syndromes

• Rare aleukemic leukemia (acute myelogenous leukemia)

• Some acute lymphoblastic leukemias

• Some lymphomas of bone marrow

HYPOCELLULAR BONE MARROW ± CYTOPENIA

• Q fever

• Legionnaires’ disease

• Mycobacteria tuberculosis

• Anorexia nervosa, starvation

• Hypothyroidism

Panic Disorder

MEDICAL CONDITIONS

• Endocrinopathies

• Hyperthyroidism

• Hyperparathyroidism

• Pheochromocytoma

• Carcinoid tumor

• Cardiac and respiratory diseases

• Arrhythmias

• Myocardial infarction

• Chronic obstructive pulmonary disease

• Asthma

• Metabolic

• Hypoglycemia

• Electrolyte imbalances

• Porphyria

• Seizure disorders

• Psychiatric disorders (NOTE: Panic attacks are common in a variety of psychiatric disorders. Panic disorder could be conceptualized as a phobia of the somatic sensations or situations that have become paired with panic attacks.)

• Phobias (e.g., specific phobia or social phobia)

• Obsessive-compulsive disorder (cued by exposure to the object of the obsession)

• Post-traumatic stress disorder (cued by recall of a stressor)

• Therapeutic (theophylline, steroids) and recreational (cocaine, amphetamine, caffeine, diet pills) drugs and drug withdrawal (alcohol, barbiturates, benzodiazepines)

Papilledema

• CNS infections (viral, bacterial, fungal)

• Medications (e.g., lithium, cisplatin, corticosteroids, tetracycline)

• Head trauma

• CNS neoplasm (primary or metastatic)

• Pseudotumor cerebri

• Cavernous sinus thrombosis

• Systemic lupus erythematosus (SLE)

• Sarcoidosis

• Subarachnoid hemorrhage

• Carbon dioxide retention

• Arnold-Chiari malformation and other developmental or congenital malformations

• Orbital lesions

• Central retinal vein occlusion

• Hypertensive encephalopathy

• Metabolic abnormalities

Papulosquamous Diseases ¹⁴

• Psoriasis

• Pityriasis rubra pilaris

• Pityriasis lichenoides

Paraneoplastic Neurologic Syndromes

• Lambert-Eaton myasthenic syndrome

• Myasthenia gravis

• Guillain-Barré syndrome

• Amyotrophic lateral sclerosis

• Dermatomyositis

• Carcinoid myopathy

• Cerebellar degeneration

• Encephalomyelitis

• Optic neuritis, uveitis, retinopathy

• Stiff-man syndrome

• Autonomic neuropathy

• Brachial neuritis

• Sensory neuropathy

• Progressive multifocal leukoencephalopathy

Paraneoplastic Syndromes, Endocrine ³⁷

• Hypercalcemia

• Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

• Hypoglycemia

• Zollinger-Ellison syndrome

• Ectopic secretion of human chorionic gonadotropin (hCG)

• Cushing’s syndrome

Paraneoplastic Syndromes, Nonendocrine ³⁷

CUTANEOUS

• Dermatomyositis

• Acanthosis nigricans

• Sweet’s syndrome

• Erythema gyratum repens

• Systemic nodular panniculitis (Weber-Christian disease)

RENAL

• Nephrotic syndrome

• Nephrogenic diabetes insipidus

NEUROLOGIC

• Subacute cerebellar degeneration

• Progressive multifocal leukoencephalopathy

• Subacute motor neuropathy

• Sensory neuropathy

• Ascending acute polyneuropathy (Guillain-Barré syndrome)

• Myasthenic syndrome (Eaton-Lambert syndrome)

HEMATOLOGIC

• Microangiopathic hemolytic anemia

• Migratory thrombophlebitis (Trousseau’s syndrome)

• Anemia of chronic disease

RHEUMATOLOGIC

• Polymyalgia rheumatica

• Hypertrophic pulmonary osteoarthropathy

Paranoid Personality Disorder

• Schizophrenia (paranoid type), delusional disorder (paranoid type), and mood disorder with psychotic symptoms: require presence of persistent positive psychotic symptoms such as delusions and hallucinations. To give an additional diagnosis of paranoid personality disorder (PPD), the personality disorder must be present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission.

• Substance-induced paranoia, especially in the context of cocaine or methamphetamine abuse or dependence

• Personality changes due to a general medical condition that affects the central nervous system

• Paranoid traits associated with a sensory disability, for example, hearing impairment

• The most common co-occurring personality disorders are schizotypal, schizoid, narcissistic, avoidant, and borderline:

• Schizotypal personality disorder includes magical thinking and unusual perceptual experiences.

• Schizoid and borderline personality disorders do not have prominent paranoid ideation.

• Avoidant personality disorder includes fear of embarrassment.

• Narcissistic personality disorder includes the fear that hidden “flaws” or “inferiority” may be revealed.

Paraplegia

• Trauma: penetrating wounds to motor cortex, fracture-dislocation of vertebral column with compression of spinal cord or cauda equina, prolapsed disk, electrical injuries

• Neoplasm: parasagittal region, vertebrae, meninges, spinal cord, cauda equina; Hodgkin’s disease, non-Hodgkin’s lymphoma (NHL), leukemic deposits, pelvic neoplasms

• Multiple sclerosis (MS) and other demyelinating disorders

• Mechanical compression of spinal cord, cauda equina, or lumbosacral plexus: Paget’s disease, kyphoscoliosis, herniation of intervertebral disk, spondylosis, ankylosing spondylitis, rheumatoid arthritis (RA), aortic aneurysm

• Infections: spinal abscess, syphilis, TB, poliomyelitis, leprosy

• Thrombosis of superior sagittal sinus

• Polyneuritis: Guillain-Barré syndrome, diabetes, alcohol, beriberi, heavy metals

• Heredofamilial muscular dystrophies

• Amyotrophic lateral sclerosis (ALS)

• Congenital and familial conditions: syringomyelia, myelomeningocele, myelodysplasia

• Hysteria

Paresthesias

• Multiple sclerosis (MS)

• Nutritional deficiencies (thiamine, vitamin B₁₂, folic acid)

• Compression of spinal cord or peripheral nerves

• Medications (e.g., isonicotinic acid hydrazide [INH], lithium, nitrofurantoin, gold, cisplatin, hydralazine, amitriptyline, sulfonamides, amiodarone, metronidazole, dapsone, disulfiram, chloramphenicol)

• Toxic chemicals (e.g., lead, arsenic, cyanide, mercury, organophosphates)

• Diabetes mellitus (DM)

• Infections (HIV, Lyme disease, herpes zoster, leprosy, diphtheria)

• Charcot-Marie-Tooth syndrome and other hereditary neuropathies

• Guillain-Barré neuropathy

Parkinson’s Disease

• Multisystem atrophy: distinguishing features of autonomic dysfunction, including urinary incontinence, orthostatic hypotension, and erectile dysfunction; parkinsonism, cerebellar signs, and normal cognition

• Diffuse Lewy body disease: parkinsonism with concomitant dementia. Patients often have early hallucinations and fluctuations in level of alertness and mental status.

• Corticobasal degeneration: often begins asymmetrically with apraxia, cortical sensory loss in one limb, and sometimes alien limb phenomenon

• Progressive supranuclear palsy: tends to have axial rigidity greater than appendicular (limb) rigidity. These patients have early and severe postural instability. Hallmark is supranuclear gaze palsy that usually involves vertical gaze before horizontal.

• Essential tremor

• Secondary (acquired) parkinsonism

• Postinfectious parkinsonism: von Economo’s encephalitis

• Parkinson’s pugilistica: after repeated head trauma

• Iatrogenic: any of the neuroleptics and antipsychotics. The high-potency D₂ blocker neuroleptics are most likely to cause parkinsonism.

• Toxins (e.g., 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine [MPTP], manganese, carbon monoxide)

• Cerebrovascular disease (basal ganglia infarcts)

Parkinson’s Plus Syndromes

• Parkinson’s disease

• Shy-Drager syndrome

• Corticobasal degeneration

• Olivopontocerebellar atrophy

• Dementia with Lewy bodies

• Progressive supranuclear palsy

• Striatonigral degeneration

Paronychia

• Squamous cell carcinoma

Parotid Swelling ³

NONPAROTID SWELLING

• Hypertrophy of masseter muscle

• Lymphadenopathy

• Rheumatoid mandibular joint swelling

• Tumors of jaw

• Infantile cortical hyperostosis

Paroxysmal Cold Hemoglobinuria (PCH)

OTHER CAUSES OF RED OR BROWN URINE

• Beet ingestion

• Medications (e.g., phenazopyridine)

• Myoglobinuria

• Hematuria

OTHER CAUSES OF HEMOLYSIS

• Hemoglobinopathies

• Erythrocyte membrane defects

• Medications, toxins

• Microangiopathy

• Other forms of autoimmune hemolysis

Pediculosis

• Seborrheic dermatitis

• Scabies

• Eczema

• Other: pilar casts, trichonodosis (knotted hair), monilethrix

Pedophilia

• Psychosis: may present with unusual ideas or statements that may rarely be confused with pedophilia; but statements or behaviors of psychotic individuals are usually disorganized and relatively short-lived.

• Incest: some is not based in pedophilia but may instead reflect a dysfunctional family unit.

• Paraphilic sexual behavior in the setting of another condition, such as mental retardation, brain injury, or drug intoxication

Pelvic Inflammatory Disease

• Ectopic pregnancy

• Appendicitis

• Ruptured ovarian cyst

• Endometriosis

• Urinary tract infection (cystitis or pyelonephritis)

• Renal calculus

• Adnexal torsion

• Proctocolitis

Pelvic Mass

• Hemorrhagic ovarian cyst

• Simple ovarian cyst (follicle or corpus luteum)

• Ovarian carcinoma, carcinoma of fallopian tube, colorectal carcinoma, metastatic carcinoma, prostate carcinoma, bladder carcinoma, lymphoma, Hodgkin’s disease

• Cystadenoma, teratoma, endometrioma

• Diverticulitis, diverticular abscess

• Appendiceal abscess, tubo-ovarian abscess

• Ectopic pregnancy, intrauterine pregnancy

Pelvic Pain, Chronic ⁷

MUSCULOSKELETAL DISORDERS

• Myofascial pain syndrome

GASTROINTESTINAL DISORDERS

• Irritable bowel syndrome

• Inflammatory bowel disease

URINARY TRACT DISORDERS

• Interstitial cystitis

• Nonbacterial urethritis

Pelvic Pain, Genital Origin ²⁷

PERITONEAL IRRITATION

• Ruptured ectopic pregnancy

• Ovarian cyst rupture

• Ruptured tubo-ovarian abscess

• Uterine perforation

TORSION

• Ovarian cyst or tumor

• Pedunculated fibroid

INTRATUMOR HEMORRHAGE OR INFARCTION

• Ovarian cyst

• Solid ovarian tumor

• Uterine leiomyoma

INFECTION

• Endometritis

• Pelvic inflammatory disease (PID)

• Trichomonas cervicitis or vaginitis

• Tubo-ovarian abscess

PREGNANCY RELATED

First Trimester

• Ectopic pregnancy

• Abortion

• Corpus luteum hematoma

Late Pregnancy

• Placental problems

• Preeclampsia

• Premature labor

MISCELLANEOUS

• Primary dysmenorrhea

Pemphigus Vulgaris

• Bullous pemphigoid

• Cicatricial pemphigoid

• Behçet’s syndrome

• Erythema multiforme

• Systemic lupus erythematosus

• Aphthous stomatitis

• Dermatitis herpetiformis

• Drug eruptions

Penile Rash

• Herpes simplex 2

• Balanitis (Candida)

• Condylomata acuminata

• Molluscum contagiosum

• Scabies

• Pediculosis pubis

• Pearly penile papules

• Lichen nitidus

• Fox-Fordyce disease (follicular papules)

Peptic Ulcer Disease

• Gastroesophageal reflux disease (GERD)

• Cholelithiasis syndrome

• Pancreatitis

• Gastritis

• Nonulcer dyspepsia

• Neoplasm (gastric carcinoma, lymphoma, pancreatic carcinoma)

• Angina pectoris, myocardial infarction (MI), pericarditis

• Dissecting aneurysm

• Other: high small bowel obstruction, pneumonia, subphrenic abscess, early appendicitis

Perianal Pain ³⁹

• Fissure in ano

• Anal sepsis

• Anal abscess–anal fistula

• Hemorrhoids

• Internal hemorrhoids

• External hemorrhoids

• Pruritus ani

• Proctalgia fugax

• Chronic perianal pain syndromes

• Coccygodynia

• Descending perineum syndrome

• Levator ani syndrome

• Idiopathic perineal pain

Pericardial Effusion

• Pericarditis

• Uremia

• Myxedema

• Neoplasm (leukemia, lymphoma, metastatic)

• Hemorrhage (trauma, leakage of thoracic aneurysm)

• Systemic lupus erythematosus (SLE), rheumatoid disease

• Myocardial infarction

Pericarditis

• Angina pectoris

• Pulmonary infarction

• Dissecting aneurysm

• GI abnormalities (e.g., hiatal hernia, esophageal rupture)

• Pneumothorax

• Hepatitis

• Cholecystitis

• Pneumonia with pleurisy

Periodic Paralysis, Hyperkalemic

• Chronic renal failure

• Renal insufficiency with excessive potassium supplementation

• Potassium-sparing diuretics

• Endocrinopathies (hypoaldosteronism, adrenal insufficiency)

Periodic Paralysis, Hypokalemic

• Chronic diarrhea (laxative abuse, sprue, villous adenoma)

• Potassium-depleting diuretics

• Medications (amphotericin B, corticosteroids)

• Chronic licorice ingestion

• Thyrotoxicosis

• Renal tubular acidosis

• Conn’s syndrome

• Bartter’s syndrome

• Barium intoxication

Peripheral Arterial Disease

• Spinal stenosis

• Degenerative joint disease of the lumbar spine and hips

• Muscle cramps

• Compartment syndrome

Peritoneal Carcinomatosis ¹⁴

• Primary disorders of the peritoneum: mesothelioma

• Metastatic spread from

• Other intra-abdominal organs

• Ovary

• Pseudomyxoma peritonei

• Extra-abdominal primary tumors

• Breast

• Lung

• Hematologic malignant neoplasm

• Lymphoma

Peritoneal Effusion ¹⁹

TRANSUDATES

Increased Hydrostatic Pressure or Decreased Plasma Oncotic Pressure

• Congestive heart failure (CHF)

• Hepatic cirrhosis

• Hypoproteinemia

EXUDATES

Increased Capillary Permeability or Decreased Lymphatic Resorption

• Infections (TB, spontaneous bacterial peritonitis, secondary bacterial peritonitis)

• Neoplasms (hepatoma, metastatic carcinoma, lymphoma, mesothelioma)

• Trauma

• Pancreatitis

• Bile peritonitis (e.g., ruptured gallbladder)

CHYLOUS EFFUSION

Damage or Obstruction to Thoracic Duct

• Parasitic infection

Peritonitis, Secondary

• Postoperative: abscess, sepsis, bowel obstruction, injury to internal organs

• Gastrointestinal: perforated viscus, appendicitis, inflammatory bowel disease (IBD), infectious colitis, diverticulitis, acute cholecystitis, peptic ulcer perforation, pancreatitis, bowel obstruction

• Gynecologic: ruptured ectopic pregnancy, pelvic inflammatory disease (PID), ruptured hemorrhagic ovarian cyst, ovarian torsion, degenerating leiomyoma

• Urologic: nephrolithiasis, interstitial cystitis

• Miscellaneous: abdominal trauma, penetrating wounds, infections secondary to intraperitoneal dialysis

• Spontaneous bacterial peritonitis

Peritonitis, Spontaneous Bacterial

• Appendicitis (in children)

• Perforated peptic ulcer

• Secondary peritonitis

• Peritoneal abscess

• Splenic, hepatic, or pancreatic abscess

• Cholecystitis

• Cholangitis

Peritonsillar Abscess

• Tonsillitis

• Infectious mononucleosis

• Peritonsillar cellulitis

• Retropharyngeal abscess

• Epiglottitis

• Dental abscess

• Lymphoma

Periumbilical Swelling

• Umbilical hernia

• Lipoma

• Epigastric hernia

• Umbilical granuloma

• Omphalocele

• Gastroschisis

• Caput medusae

Pertussis

• Croup

• Epiglottitis

• Foreign body aspiration

• Bacterial pneumonia

Peutz-Jeghers Syndrome

• Familial adenomatous polyposis

• Juvenile polyposis

• Turcot’s syndrome

• Cowden disease

Pheochromocytoma

• Anxiety disorder

• Thyrotoxicosis

• Amphetamine or cocaine abuse

• Carcinoid

• Essential hypertension

Phobias

• Panic attacks: anxiety symptoms seen in specific phobia may resemble panic attacks, but the stimulus in specific phobias or social phobias is clear, whereas panic attacks seem more random.

• Generalized anxiety disorder: difficult to distinguish from social phobia; but in social phobia, the cognitive focus is fear of embarrassment or humiliation, whereas in generalized anxiety disorder, the focus is more internal on the subjective sensations of discomfort.

Photodermatoses ¹⁴

• Polymorphous light eruption

• Chronic actinic dermatitis

• Solar urticaria

• Phototoxicity and photoallergy

• Porphyrias

Photosensitivity

• Solar urticaria

• Photoallergic reaction

• Phototoxic reaction

• Polymorphous light eruption

• Porphyria cutanea tarda

• Systemic lupus erythematosus (SLE)

• Drug induced (e.g., tetracyclines)

Pilar Cyst (Wen)

Pilonidal Disease

• Perianal abscess arising from the posterior midline crypt

• Hidradenitis suppurativa

Pinworms

• Perianal itching related to poor hygiene

• Hemorrhoidal disease and anal fissures

• Perineal yeast/fungal infections

Pituitary Adenoma

ACROMEGALY

• Ectopic production of GH-releasing hormone from a carcinoid or other neuroendocrine tumor

CUSHING’S DISEASE

• Diseases that cause ectopic sources of ACTH overproduction (including small cell carcinoma of the lung, bronchial carcinoid, intestinal carcinoid, pancreatic islet cell tumor, medullary thyroid carcinoma, and pheochromocytoma)

• Adrenal adenomas, adrenal carcinoma

• Nelson’s syndrome

THYROTROPIN-SECRETING PITUITARY ADENOMAS

• Primary hypothyroidism

NONSECRETORY PITUITARY ADENOMA

• Non-neoplastic mass lesions of various etiologies (e.g., infectious, granulomatous)

Pityriasis Alba

• Chemical leukoderma

Pityriasis Rosea

• Tinea corporis (can be ruled out by potassium hydroxide examination)

• Secondary syphilis (absence of herald patch, positive serologic test result for syphilis)

• Tinea versicolor (the lesions are more brown and the borders are not as ovoid)

Placenta Previa

• Vaginal or cervical trauma

• Labor

• Local malignant neoplasm

Plantar Fasciitis

• Other regional tendinitis

• Stress fracture

• Tarsal tunnel syndrome

• Tumor, infection

Pleural Effusions

TRANSUDATIVE

• Congestive heart failure (CHF)

• Hepatic cirrhosis

• Nephrotic syndrome

• Hypoproteinemia from any cause

• Meigs’ syndrome

Pleural Effusions, Malignant Disease Associated

• Lung cancer (30% to 40%)

• Breast cancer (20% to 25%)

• Lymphoma (10% to 15%)

• Leukemia (5% to 10%)

• GI tract (5%)

• GU tract (5%)

• Reproductive (3%)

Pneumonia, Bacterial

• Exacerbation of chronic bronchitis

• Pulmonary embolism or infarction

• Lung neoplasm

• Bronchiolitis

• Sarcoidosis

• Hypersensitivity pneumonitis

• Pulmonary edema

• Drug-induced lung injury

• Viral pneumonias

• Fungal pneumonias

• Parasitic pneumonias

• Atypical pneumonia

• Tuberculosis

Pneumonia, Mycoplasma

• Chlamydia pneumoniae

• Chlamydia psittaci

• Legionella spp.

• Coxiella burnetii

• Several viral agents

• Q fever

• Streptococcus pneumoniae

• Pleuritic pain

• Pulmonary embolism/infarction

Pneumonia, Pneumocystis jiroveci

OTHER OPPORTUNISTIC RESPIRATORY INFECTIONS

• Tuberculosis

• Histoplasmosis

• Cryptococcosis

NONOPPORTUNISTIC INFECTIONS

• Bacterial pneumonia

• Viral pneumonia

• Mycoplasmal pneumonia

• Legionellosis

Pneumonia, Recurrent

• Mechanical obstruction from neoplasm

• Chronic aspiration (tube feeding, alcoholism, cerebrovascular accident [CVA], neuromuscular disorders, seizure disorder, inability to cough)

• Bronchiectasis

• Kyphoscoliosis

• Chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), asthma, silicosis, pulmonary fibrosis, cystic fibrosis

• Pulmonary TB, chronic sinusitis

• Immunosuppression (HIV infection, corticosteroids, leukemia, chemotherapy, splenectomy)

Pneumonia, Viral

• Bacterial pneumonia, which frequently complicates (i.e., can follow or be simultaneous with) viral (especially influenza) pneumonia

• Other causes of atypical pneumonia: Mycoplasma, Chlamydia, Coxiella, legionnaires’ disease

• Acute respiratory distress syndrome (ARDS)

• Pulmonary emboli

Pneumothorax, Spontaneous

• Pleurisy

• Pulmonary embolism

• Myocardial infarction

• Pericarditis

• Asthma

• Pneumonia

Poliomyelitis

• Guillain-Barré syndrome

• Cerebrovascular accident (CVA)

• Spinal cord compression

• Other enteroviruses

Polyarteritis Nodosa

• Cryoglobulinemia

• Systemic lupus erythematosus (SLE)

• Infections (e.g., subacute bacterial endocarditis [SBE], trichinosis, rickettsia)

• Lymphoma

Polycystic Kidney Disease

• Simple cysts

• Tuberous sclerosis

• von Hippel–Lindau syndrome

• Acquired cystic kidney disease

Polycystic Ovary Syndrome (PCOS)

CAUSES OF HIRSUTISM

Polycythemia Vera

• Smoking: polycythemia is secondary to increased carboxyhemoglobin, resulting in left shift in the Hgb dissociation curve. Laboratory evaluation shows increased hematocrit (Hct), red blood cell (RBC) mass, erythropoietin level, and carboxyhemoglobin. Splenomegaly is not present on physical examination.

• Hypoxemia (secondary polycythemia): living for prolonged periods at high altitudes, pulmonary fibrosis, congenital cardiac lesions with right-to-left shunts. Laboratory evaluation shows decreased arterial oxygen saturation and elevated erythropoietin level. Splenomegaly is not present on physical examination.

• Erythropoietin-producing disorders: renal cell carcinoma, hepatoma, cerebral hemangioma, uterine fibroids, polycystic kidneys. The erythropoietin level is elevated in these patients; the arterial oxygen saturation is normal. Splenomegaly may be present with metastatic neoplasms.

• Stress polycythemia (Gaisböck’s syndrome, relative polycythemia): laboratory evaluation demonstrates normal RBC mass, arterial oxygen saturation, and erythropoietin level; plasma volume is decreased. Splenomegaly is not present on physical examination.

• Hemoglobinopathies associated with high oxygen affinity: an abnormal oxyhemoglobin dissociation curve (P50) is present.

Polymorphous Light Eruption

• Reticular erythematous mucinosis (clinically, polymorphous light eruption resolves once exposure to sunlight has ceased, in contrast to the persistent lesions of reticular erythematous mucinosis)

• Lymphocytic infiltration (on histologic examination, marked papillary edema favors polymorphic light eruption)

• SLE (most cases of polymorphic light eruption are negative with immunofluorescence testing)

Polymyalgia Rheumatica

• Rheumatoid arthritis (RA): rheumatoid factor is absent in polymyalgia

• Polymyositis: enzyme studies are normal in polymyalgia

• Fibromyalgia

• Viral syndrome

Polymyositis

• Dermatomyositis

• Muscular dystrophies

• Amyotrophic lateral sclerosis (ALS)

• Myasthenia gravis or Eaton-Lambert syndrome

• Guillain-Barré syndrome

• Alcoholic myopathy

• Fibromyalgia

• Drug-induced myopathies (e.g., HMG reductase inhibitors, gemfibrozil)

• Diseases associated with polymyositis (e.g., sarcoidosis, HIV infection)

• Inclusion body myositis

Polyneuropathy ⁴⁰

PREDOMINANTLY MOTOR

• Guillain-Barré syndrome

• Porphyria

• Diphtheria

• Lead

• Hereditary sensorimotor neuropathy, types I and II

• Paraneoplastic neuropathy

PREDOMINANTLY SENSORY

• Paraneoplastic neuropathy

• Vitamin B₁₂ deficiency

• Hereditary sensory neuropathy, types I-IV

PREDOMINANTLY AUTONOMIC

• Diabetes

• Amyloidosis

• Alcoholic neuropathy

• Familial dysautonomias

MIXED SENSORIMOTOR

• Systemic diseases: renal failure, hypothyroidism, acromegaly, rheumatoid arthritis, periarteritis nodosa, systemic lupus erythematosus (SLE), multiple myeloma, macroglobulinemia, remote effect of malignant neoplasm

• Medications: isoniazid, nitrofurantoin, ethambutol, chloramphenicol, chloroquine, vincristine, vinblastine, dapsone, disulfiram, diphenylhydantoin, cisplatin, l-tryptophan

• Environmental toxins: n-hexane, methyl n-butyl ketone, acrylamide, carbon disulfide, carbon monoxide, hexachlorophene, organophosphates

• Deficiency disorders: malabsorption, alcoholism, vitamin B₁ deficiency, Refsum’s disease, metachromatic leukodystrophy

Polyneuropathy, Drug Induced ⁴⁰

DRUGS IN ONCOLOGY

• Metronidazole (Flagyl)

• Taxol

DRUGS IN INFECTIOUS DISEASES

• Isoniazid

• Nitrofurantoin

• Dapsone

• ddC (dideoxycytidine)

• ddI (dideoxyinosine)

DRUGS IN CARDIOLOGY

• Hydralazine

• Perhexiline maleate

• Procainamide

• Disopyramide

DRUGS IN RHEUMATOLOGY

• Gold salts

• Chloroquine

DRUGS IN NEUROLOGY AND PSYCHIATRY

• Diphenylhydantoin

• Glutethimide

• Methaqualone

MISCELLANEOUS

• Disulfiram (Antabuse)

• Vitamin: pyridoxine (megadoses)

Polyneuropathy, Symmetric ⁴⁰

INHERITED NEUROPATHIES

• Neuropathies with biochemical markers: Refsum’s disease, Bassen-Kornzweig disease, Tangier disease, metachromatic leukodystrophy, Krabbe’s disease, adrenomyeloneuropathy, Fabry’s disease

• Neuropathies without biochemical markers or systemic involvement: hereditary motor neuropathy, hereditary sensory neuropathy, hereditary sensorimotor neuropathy

Polyuria

• Diabetes mellitus (DM)

• Diabetes insipidus

• Primary polydipsia (compulsive water drinking)

• Hypercalcemia

• Hypokalemia

• Postobstructive uropathy

• Diuretic phase of renal failure

• Drugs: diuretics, caffeine, alcohol, lithium

• Sickle cell trait or disease, chronic pyelonephritis (failure to concentrate urine)

• Anxiety, cold weather

Popliteal Swelling

• Phlebitis (superficial)

• Lymphadenitis

• Trauma: fractured tibia or fibula, contusion, traumatic neuroma

• Deep venous thrombosis (DVT)

• Ruptured varicose vein

• Aneurysm of popliteal artery

• Neoplasm: lipoma, osteogenic sarcoma, neurofibroma, fibrosarcoma

Porphyria Cutanea Tarda (PCT)

• Pseudoporphyria

• Porphyria variegata

• Polymorphous light eruption

• Bullous pemphigoid

• Bullous lupus

Portal Hypertension ¹

INCREASED RESISTANCE TO FLOW

• Presinusoidal: portal or splenic vein occlusion (thrombosis, tumor), schistosomiasis, congenital hepatic fibrosis, sarcoidosis

• Sinusoidal: cirrhosis (all causes), alcoholic hepatitis

• Postsinusoidal: veno-occlusive disease, Budd-Chiari syndrome, constrictive pericarditis

INCREASED PORTAL BLOOD FLOW

• Splenomegaly not due to liver disease

• Arterioportal fistula

Postconcussive Syndrome

• Headache (vascular or tension)

• Epidural hematoma

• Subdural hematoma

• Skull fracture

• Cervical spine disk disease

• Whiplash

• Seizure

• Cerebrovascular accident

• Depression

• Anxiety

Postmenopausal Bleeding

• Hormone replacement therapy

• Neoplasm (uterine, ovarian, cervical, vaginal, vulvar)

• Atrophic vaginitis

• Vaginal infection

• Polyp

• Extragenital (GI, urinary)

• Tamoxifen

• Trauma

Postpoliomyelitis Syndrome

• Amyotrophic lateral sclerosis

• Cervical and lumbosacral radiculopathy

• Adult spinal muscular atrophy

• Diabetic amyotrophy

• Multifocal motor neuropathy with conduction block

• Chronic inflammatory demyelinating polyneuropathy

• Entrapment neuropathies

• Inflammatory and metabolic myopathies

• Vasculitis

• Connective tissue disease–associated myopathies

Post-traumatic Stress Disorder

• Adjustment disorders are distinguished from PTSD in that the precipitating stress is less catastrophic and the psychological reaction less specific.

• Acute stress disorder, if symptoms last between 48 hours and 4 weeks after trauma

• Delayed-onset PTSD, if symptoms develop >6 months after the event

• Major depression; up to 30% of primary care patients with depression also have PTSD

Postural Hypotension, Non-neurologic Causes

• Diuretics and hypertensive agents

• GI hemorrhage

• Alcohol

• Excessive heat

• Rapid volume loss from diarrhea, vomiting

• Hemodialysis

• Extensive burns

• Pyrexia

• Aortic stenosis (impaired output)

• Constrictive pericarditis, atrial myxoma (impaired cardiac filling)

• Adrenal insufficiency

• Diabetes insipidus

• Vasodilatory agents (e.g., nitrates)

Precocious Puberty

• Most common diagnoses to consider: premature thelarche and premature adrenarche

• Gonadotropin hormone–releasing hormone (GnRH)–dependent precocious puberty: idiopathic, CNS tumors, hypothalamic hamartomas, neurofibromatosis, tuberous sclerosis, hydrocephalus, post acute head injury, ventricular cysts, post CNS infection

• GnRH-independent precocious puberty: congenital adrenal hyperplasia, adrenocortical tumors (males), McCune-Albright syndrome (females), gonadal tumors, ectopic human chorionic gonadotropin (hCG)–secreting tumors (chorioblastoma, hepatoblastoma), exposure to exogenous sex steroids, severe hypothyroidism

Preeclampsia

• Acute fatty liver of pregnancy

• Appendicitis

• Diabetic ketoacidosis

• Gallbladder disease

• Gastroenteritis

• Glomerulonephritis

• Hemolytic-uremic syndrome

• Hepatic encephalopathy

• Hyperemesis gravidarum

• Idiopathic thrombocytopenia

• Thrombotic thrombocytopenic purpura

• Nephrolithiasis

• Pyelonephritis

• Peptic ulcer disease (PUD)

• Systemic lupus erythematosus (SLE)

Premature Graying, Scalp Hair

• Chemical exposure (e.g., phenol/catechol derivatives, sulfhydryls, arsenic)

• Physical agents (e.g., ionizing radiation, lasers)

• Hyperthyroidism

• Vitamin B₁₂ deficiency

• Down syndrome

• Chronic and severe protein deficiency

• Vitiligo

• Idiopathic

• Myotonic dystrophy

• Ataxia-telangiectasia

• Progeria

• Wermer’s syndrome

Premenstrual Dysphoric Disorder

• Premenstrual syndrome

• Dysthymic syndrome

• Personality disorder

• Panic disorder

• Major depressive disorder

• Hyperthyroidism

• Polycystic ovary syndrome

Progressive Supranuclear Palsy

• Parkinson’s disease: differs from PSP in that the latter is characterized by prominence of early falls, tremor being unusual, and little response to levodopa.

• Cortical basal ganglionic degeneration: differentiated from PSP by presence of cortical sensory signs and asymmetric limb apraxia.

• Multiple systems atrophy: differs from PSP by the presence of prominent autonomic symptoms or cerebellar signs.

• Dementia with Lewy bodies (DLB): in PSP, visual hallucinations typically occur only if provoked by dopaminergic therapy; whereas in DLB, there are prominent visual hallucinations that may be spontaneous or provoked.

Prolactinoma

• Drugs: phenothiazines, methyldopa, reserpine, monoamine oxidase (MAO) inhibitors, androgens, progesterone, cimetidine, tricyclic antidepressants, haloperidol, meprobamate, chlordiazepoxide, estrogens, narcotics, metoclopramide, verapamil, amoxapine, cocaine, oral contraceptives

• Hepatic cirrhosis, renal failure, primary hypothyroidism

• Ectopic prolactin-secreting tumors (hypernephroma, bronchogenic carcinoma)

• Infiltrating diseases of the pituitary (sarcoidosis, histiocytosis)

• Head trauma, chest wall injury, spinal cord injury

• Polycystic ovary disease, pregnancy, nipple stimulation

• Idiopathic hyperprolactinemia, stress, exercise

Pronator Syndrome

• Carpal tunnel syndrome

• Cervical disk syndrome with radiculopathy

• Tendon rupture

• Tendinitis

Proptosis ³¹

• Thyrotoxicosis

• Orbital pseudotumor

• Optic nerve tumor

• Cavernous sinus arteriovenous (AV) fistula, cavernous sinus thrombosis

• Cellulitis

• Metastatic tumor to orbit

Proptosis and Palatal Necrotic Ulcers

• Cavernous sinus thrombosis

• Bacterial orbital cellulitis

• Metastatic neoplasm

• Rhinocerebral mucormycosis

• Ecthyma gangrenosum

• CNS aspergillosis

Prostate Cancer

• Benign prostatic hypertrophy

• Prostatitis

• Prostate stones

• Metastatic neoplasm

Prostatic Hyperplasia, Benign

• Prostatitis

• Prostate cancer

• Strictures (urethral)

• Medication interfering with the muscle fibers in the prostate and also with bladder

Proteinuria

• Nephrotic syndrome as a result of primary renal diseases

• Malignant hypertension

• Malignant neoplasms: multiple myeloma, leukemias, Hodgkin’s disease

• Congestive heart failure (CHF)

• Diabetes mellitus (DM)

• Systemic lupus erythematosus (SLE), rheumatoid arthritis (RA)

• Sickle cell disease

• Goodpasture’s syndrome

• Malaria

• Amyloidosis, sarcoidosis

• Tubular lesions: cystinosis

• Functional (after heavy exercise)

• Pyelonephritis

• Pregnancy

• Constrictive pericarditis

• Renal vein thrombosis

• Toxic nephropathies: heavy metals, drugs

• Irradiation nephritis

• Orthostatic (postural) proteinuria

• Benign proteinuria: fever, heat, or cold exposure

Pruritus

• Dry skin

• Drug-induced eruption, fiberglass exposure

• Scabies

• Skin diseases

• Myeloproliferative disorders: mycosis fungoides, Hodgkin’s disease, multiple myeloma, polycythemia vera

• Cholestatic liver disease

• Endocrine disorders: diabetes mellitus (DM), thyroid disease, carcinoid, pregnancy

• Carcinoma: breast, lung, gastric

• Chronic renal failure

Pruritus Ani ²⁷

FECAL IRRITATION

• Poor hygiene

• Anorectal conditions (fissure, fistula, hemorrhoids, skin tags, perianal clefts)

• Spicy foods, citrus foods, caffeine, colchicine, quinidine

CONTACT DERMATITIS

• Anesthetic agents, topical corticosteroids, perfumed soap

DERMATOLOGIC DISORDERS

• Psoriasis, seborrhea, lichen simplex or sclerosus

SYSTEMIC DISORDERS

• Chronic renal failure, myxedema, diabetes mellitus (DM), thyrotoxicosis, polycythemia vera, Hodgkin’s disease

SEXUALLY TRANSMITTED DISEASES

• Syphilis, herpes simplex virus, human papillomavirus

OTHER INFECTIOUS AGENTS

• Pinworms

• Scabies

• Bacterial infection, viral infection

Pruritus Vulvae

• Vulvitis

• Vaginitis

• Lichen sclerosus

• Squamous cell hyperplasia

• Pinworms

• Vulvar cancer

• Syringoma of the vulva

Pseudocyanosis, Etiology

• Medications: amiodarone, minocycline, chlorpromazine

• Heavy metals

• Gold (systemic absorption)

• Silver (systemic absorption)

• Local contact with color dyes, gold, silver

Pseudofolliculitis Barbae (Ingrown Hairs, Razor Bumps)

Pseudogout

• Gouty arthritis

• Rheumatoid arthritis

• Osteoarthritis

• Neuropathic joint

• Infectious arthritis

• Osteomyelitis

• Trauma

Pseudohermaphroditism, Female

• Congenital adrenal hyperplasia

• Maternal use of testosterone or related steroids

• Virilizing ovarian or adrenal tumor

• Virilizing luteoma of pregnancy

• Disturbances in differentiation of urogenital structures, non–androgen related

• Maternal virilizing adrenal hyperplasia

• Fetal P450 aromatase deficiency

Pseudohermaphroditism, Male

• Maternal ingestion of progestogens

• End-organ resistance to androgenic hormones

• 5α-Reductase 2 deficiency

• XY gonadal dysgenesis

• Testicular regression syndrome

• Defects in testosterone metabolism by peripheral tissues

• Testosterone biosynthesis defects

Pseudoinfarction ²³

• Cardiac tumors, primary and secondary

• Cardiomyopathy (particularly hypertrophic and dilated)

• Chagas’ disease

• Chest deformity

• Chronic obstructive pulmonary disease (COPD) (particularly emphysema)

• HIV infection

• Hyperkalemia

• Left anterior fascicular block

• Left bundle branch block

• Left ventricular hypertrophy

• Myocarditis and pericarditis

• Normal variant

• Pneumothorax

• Poor R wave progression, rotational changes, and lead placement

• Pulmonary embolism

• Trauma to chest (nonpenetrating)

• Wolff-Parkinson-White syndrome

• Rare causes: pancreatitis, amyloidosis, sarcoidosis, scleroderma

Pseudomembranous Colitis

• GI bacterial infections (e.g., Salmonella, Shigella, Campylobacter, Yersinia)

• Enteric parasites (e.g., Cryptosporidium, Entamoeba histolytica)

• Inflammatory bowel disease (IBD)

• Celiac sprue

• Irritable bowel syndrome

Pseudoxanthoma Elasticum

• Ehlers-Danlos syndrome

Psittacosis

• Legionella

• Mycoplasma

• Chlamydia pneumoniae

• Viral respiratory infections

• Bacterial pneumonia

• Typhoid fever

• Viral hepatitis

• Aseptic meningitis

• Fever of unknown origin

• Mononucleosis

Psoriasis

• Nummular dermatitis

• Candidiasis

• Mycosis fungoides

• Cutaneous systemic lupus erythematosus (SLE)

• Secondary and tertiary syphilis

• Drug eruption

Psychosis ²⁹

PRIMARY

• Schizophrenia related ^*

• Major depression

• Dementia

• Bipolar disorder

Ptosis

Puberty, Delayed ²⁸

• Normal or low serum gonadotropin levels

• Constitutional delay in growth and development

• Acquired

• Bilateral gonadal failure resulting from trauma or infection or after surgery, irradiation, or chemotherapy

• Oophoritis: isolated or with other autoimmune disorders

• Uterine or vaginal disorders

• Absence of uterus or vagina

• Testicular feminization: complete or incomplete androgen insensitivity

Puberty, Precocious

• Idiopathic

• Congenital virilizing adrenal hyperplasia

• Hypothalamic tumors

• Head trauma

• Hydrocephalus

• Degenerative CNS disease

• Arachnoid cyst

• Sex chromosome abnormalities (e.g., 47,XXY, 48,XXXY)

• Perinatal asphyxia

• CNS infection (e.g., meningitis, encephalitis)

Pulmonary Crackles

• Pneumonia

• Left ventricular failure

• Asbestosis, silicosis, interstitial lung disease

• Chronic bronchitis

• Alveolitis (allergic, fibrosing)

• Neoplasm

Pulmonary Embolism

• Myocardial infarction

• GI abnormalities (e.g., peptic ulcer, esophageal rupture, gastritis)

• Congestive heart failure (CHF)

• Pleuritis

• Anxiety disorder with hyperventilation

• Pericardial tamponade

• Dissection of aorta

• Asthma

Pulmonary Hypertension, Primary

Pulmonary Lesions

• TB

• Legionella pneumonia

• Mycoplasma pneumonia

• Viral pneumonia

• Pneumocystis jiroveci

• Hypersensitivity pneumonitis

• Aspiration pneumonia

• Fungal disease (aspergillosis, histoplasmosis)

• Acute respiratory distress syndrome (ARDS) associated with pneumonia

• Multiple pulmonary emboli

• Rheumatoid nodules

Pulmonary Nodule, Solitary

• Bronchogenic carcinoma

• Granuloma from histoplasmosis

• TB granuloma

• Granuloma from coccidioidomycosis

• Metastatic carcinoma

• Bronchial adenoma

• Bronchogenic cyst

• Hamartoma

• Arteriovenous (AV) malformation

• Other: fibroma, intrapulmonary lymph node, sclerosing hemangioma, bronchopulmonary sequestration

Pulseless Electrical Activity (Electromechanical Dissociation [EMD]), Differential Diagnosis

• Pseudo-EMD

• Idioventricular rhythm

• Post defibrillation idioventricular rhythm

• Ventricular escape rhythm

• Bradyasystolic rhythm

Pulseless Electrical Activity, Etiology

• Tension pneumothorax

• Pulmonary embolus

• Drug overdose

• Hypothermia

Pupillary Dilation, Poor Response to Darkness

• Drugs (narcotics, general anesthetics, cholinergics)

• Acute trauma (spasm from prostaglandin release)

• Inflammation, infection (interruption of inhibitory fibers to the Edinger-Westphal nucleus)

• Old age (loss of inhibition at midbrain from reticular activating formation)

• Horner’s syndrome (sympathetic neuron interruption)

• Adie’s syndrome tonic pupil

• Lymphoma

• Congenital miosis

Purpura

• Trauma

• Septic emboli, atheromatous emboli

• Disseminated intravascular coagulation (DIC)

• Thrombocytopenia

• Meningococcemia

• Rocky Mountain spotted fever

• Hemolytic-uremic syndrome

• Viral infection: echovirus, coxsackievirus

• Scurvy

• Other: left atrial myxoma, cryoglobulinemia, vasculitis, hyperglobulinemic purpura

Pyelonephritis

• Nephrolithiasis

• Appendicitis

• Ovarian cyst torsion or rupture

• Acute glomerulonephritis

• Pelvic inflammatory disease (PID)

• Endometritis

• Other causes of acute abdomen

• Perinephric abscess

• Hydronephrosis

Pyoderma Gangrenosum

• Insect (spider) bite

• Vasculitis

• Traumatic ulceration

• Vascular insufficiency

• Antiphospholipid antibody syndrome

Pyogenic Granuloma

• Amelanotic melanoma

• Bacillary angiomatosis

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