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Vaginal Bleeding

ANY GESTATIONAL AGE

• Cervical lesions: polyps, decidual reaction, neoplasia
• Vaginal trauma
• Cervicitis/vulvovaginitis
• Postcoital trauma
• Bleeding dyscrasias

GESTATION <20 WEEKS

• Spontaneous abortion
• Presence of intrauterine device
• Ectopic pregnancy
• Molar pregnancy
• Implantation bleeding
• Low-lying placenta

GESTATION >20 WEEKS

• Molar pregnancy
• Placenta previa
• Placental abruption
• Vasa previa
• Marginal separation of the placenta
• Bloody show at term
• Preterm labor

Vaginal Bleeding, Pregnancy7

FIRST TRIMESTER

• Implantation bleeding
• Abortion

• Threatened
• Complete
• Incomplete
• Missed

• Ectopic pregnancy
• Neoplasia
• Hydatidiform mole
• Cervix

THIRD TRIMESTER

• Placenta previa
• Placental abruption
• Premature labor
• Choriocarcinoma

Vaginal Discharge, Prepubertal Girls20

• Irritative (bubble baths, sand)
• Poor perineal hygiene
• Foreign body
• Associated systemic illness (group A streptococci, chickenpox)
• Infections

• Escherichia coli with foreign body
• Shigella organisms
• Yersinia organisms

• Infections (consider sexual abuse)

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Trichomonas vaginalis

• Tumor (rare)

Varicocele

• Hydrocele
• Spermatocele
• Epididymal orchitis
• Testicular tumor

Varicose Veins

CONDITIONS THAT CAN LEAD TO SUPERFICIAL VENOUS STASIS OTHER THAN PRIMARY VALVULAR INSUFFICIENCY

• Arterial occlusive disease
• Diabetes
• Deep vein thrombophlebitis
• Peripheral neuropathies
• Unusual infections
• Carcinoma

Vasculitis, Classification27

LARGE-VESSEL DISEASE

Arteritis

• Giant cell arteritis
• Takayasu’s arteritis
• Arteritis associated with Reiter’s syndrome, ankylosing spondylitis

MEDIUM- AND SMALL-VESSEL DISEASE

Polyarteritis Nodosa

• Primary (idiopathic)
• Associated with viruses (hepatitis B or C, cytomegalovirus [CMV], HIV, herpes zoster)
• Associated with malignant disease (hairy cell leukemia)
• Familial Mediterranean fever

Granulomatous Vasculitis

• Wegener’s granulomatosis
• Lymphomatoid granulomatosis
• Behçet’s syndrome
• Kawasaki’s disease (mucocutaneous lymph node syndrome)

PREDOMINANTLY SMALL-VESSEL DISEASE

Hypersensitivity Vasculitis (Leukocytoclastic Vasculitis)

• Henoch-Schönlein purpura
• Mixed cryoglobulinemia
• Serum sickness
• Vasculitis associated with connective tissue diseases (systemic lupus erythematosus [SLE], Sjögren’s syndrome)
• Vasculitis associated with specific syndromes: primary biliary cirrhosis, Lyme disease, chronic active hepatitis, drug-induced vasculitis
• Churg-Strauss syndrome
• Goodpasture’s syndrome
• Erythema nodosum
• Panniculitis
• Buerger’s disease (thrombophlebitis obliterans)

Vasculitis, Diseases That Mimic Vasculitis29

EMBOLIC DISEASE

• Infectious or marantic endocarditis
• Cardiac mural thrombus
• Atrial myxoma
• Cholesterol embolization syndrome

NONINFLAMMATORY VESSEL WALL DISRUPTION

• Atherosclerosis
• Arterial fibromuscular dysplasia
• Drug effects (vasoconstrictors, anticoagulants)
• Irradiation
• Genetic disease (neurofibromatosis, Ehlers-Danlos syndrome)
• Amyloidosis
• Intravascular malignant lymphoma

DIFFUSE COAGULATION

• Disseminated intravascular coagulation (DIC)
• Thrombotic thrombocytopenic purpura
• Hemolytic-uremic syndrome
• Protein C and S deficiencies, factor V Leiden mutation
• Antiphospholipid syndrome

Venous Lake

• Hemangioma
• Melanoma
• Blue nevus
• Angiokeratoma
• Melanosis of buccal mucosa

Venous Leg Ulcers

• Peripheral arterial disease (with ischemia and necrosis)
• Diabetic ulceration (often secondary to neuropathy)
• Decubitus ulceration (due to pressure over a bone prominence)
• Vasculitis (with erythema and bullae)
• Necrotic ulceration from infection
• Basal cell carcinoma or squamous cell carcinoma

Ventricular Failure

LEFT VENTRICULAR FAILURE

• Systemic hypertension
• Valvular heart disease (aortic stenosis [AS], atrial regurgitation [AR], mitral regurgitation [MR])
• Cardiomyopathy, myocarditis
• Bacterial endocarditis
• Myocardial infarction
• Idiopathic hypertrophic subaortic stenosis

RIGHT VENTRICULAR FAILURE

• Valvular heart disease (mitral stenosis)
• Pulmonary hypertension
• Bacterial endocarditis (right sided)
• Right ventricular infarction

BIVENTRICULAR FAILURE

• Left ventricular failure
• Cardiomyopathy
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