Chapter 3. Differential Diagnosis: Symptoms, Signs, and Conditions

This chapter is a general guide to commonly encountered symptoms and conditions and their frequent causes primarily in adults unless specified. Remember: “There are more uncommon presentations of common diseases than common presentations of uncommon diseases.”

Ascites, intestinal obstruction, cysts (ovarian or renal), tumors, hepatosplenomegaly, aortic aneurysm, uterine enlargement (pregnancy), bladder distention, inflammatory mass

Diffuse:

Intestinal angina, early appendicitis, colitis, diabetic ketoacidosis, hereditary angioedema, gastroenteritis, mesenteric thrombosis, mesenteric lymphadenitis, peritonitis, porphyria, sickle cell crisis, uremia, renal colic, renal infarct, pancreatitis

Right Upper Quadrant:

Dissecting aneurysm, gallbladder disease (cholecystitis, cholangitis, choledocholithiasis), hepatitis, hepatomegaly, pancreatitis, PUD, pneumonia, pulmonary embolus, pyelonephritis, renal colic, renal infarct, appendicitis (retroperitoneal)

Left Upper Quadrant:

Dissecting aneurysm, esophagitis, hiatal hernia, esophageal rupture, gastritis, pancreatitis, PUD, myocardial infarction, pericarditis, pneumonia, pulmonary embolus, pyelonephritis, renal colic, renal infarction, splenic abscess, splenic rupture, splenic infarction

Lower Abdomen:

Aortic aneurysm, colitis including inflammatory bowel disease, diverticulitis including Meckel diverticulum, intestinal obstruction, hernia, perforated viscus, pregnancy, ectopic pregnancy, dysmenorrhea, endometriosis, mittelschmerz (ovulation), ovarian cyst or tumor (especially with torsion), PID, renal colic, UTI, rectal hematoma, bladder distention

Right Lower Quadrant:

Appendicitis, ectopic pregnancy, ovarian cyst or tumor, salpingitis, mittelschmerz, cholecystitis, perforated duodenal ulcer, Crohn disease

Adrenal adenoma, adrenal hyperplasia (unilateral or bilateral), adrenal metastasis (solid tumors, lymphoma, leukemia), adrenocortical carcinoma, pheochromocytoma, adrenal myelolipoma, adrenal cyst, adrenal varices, hemorrhage, congenital adrenal hyperplasia, ganglioneuroma, micronodular adrenal disease

Male pattern baldness (alopecia, androgenic type in both men and women), trauma and hair pulling, congenital, tinea capitis, bacterial folliculitis, telogen arrest, anagen arrest (chemotherapy, radiation therapy), alopecia areata, discoid lupus

Pregnancy, menopause (physiologic or premature), severe illness, weight loss, stress, excessive athletic training, physiologically delayed puberty, anatomic anomaly (eg, imperforate hymen, uterine agenesis, etc), gonadal dysgenesis (eg, Turner syndrome), hypothalamic and pituitary tumors, virilizing syndromes (eg, polycystic ovaries, idiopathic hirsutism). Amenorrhea is categorized as primary (never had menses) or secondary (cessation of menses).

Hepatitis, carcinoma (most types, especially advanced), anorexia nervosa, generalized debilitating diseases, digitalis toxicity, uremia, depression, CHF, pulmonary failure, radiation exposure, chemotherapy

(See Oliguria and Anuria).

Osteoarthritis, bursitis, tendonitis, connective tissue disease (rheumatoid arthritis, SLE, rheumatic fever, scleroderma, gout, pseudogout, rheumatoid variants [ankylosing spondylitis, psoriatic arthritis, Reiter syndrome]), infection (bacterial, viral, TB, fungal Lyme disease), trauma, sarcoidosis, sickle cell anemia, hemochromatosis, amyloidosis, coagulopathy

(See Chapter 13, Peritoneal [Abdominal] Paracentesis for more details.) Use the serum albumin to ascitic albumin difference (serum albumin minus ascites albumin) to help differentiate the cause of ascites. If the difference is > 1.1, portal hypertension is present. If the difference is < 1.1, the cause is not portal hypertension). CHF, tricuspid insufficiency, constrictive pericarditis, venous occlusion (including Budd–Chiari syndrome), cirrhosis, pancreatitis, peritonitis (ruptured viscus, TB, bile leak, spontaneous bacterial), tumor (most common ovarian, gastric, uterine, unknown primary, breast, lymphoma), trauma, Meigs syndrome (ovarian fibroma associated with hydrothorax and ascites), myxedema, anasarca (hypoalbuminemia)

Herniated disk, spinal stenosis, ankylosing spondylitis, metastatic tumor, multiple myeloma, mechanical back sprain, vertebral body fracture, osteoporosis-induced fracture, infectious processes (diskitis, osteomyelitis, epidural ...