Differential Diagnosis in Primary Care

521 Pages·2011·118.58 MB·English

by  R. Douglas Collins

DIFFERENTIAL
DIAGNOSIS
IN PRIMARY CARE
F I F T H E D I T I O N
R. Douglas Collins, MD, FACP
Senior FAA Medical Examiner
Former Associate Professor of Medicine
Medical University of South Carolina
Former Associate Clinical Professor of Medicine
University of Florida School of Medicine
Chatsworth, California
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Acquisitions Editor: Sonya Seigafuse
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Library of Congress Cataloging-in-Publication Data
Collins, R. Douglas.
Differential diagnosis in primary care / R. Douglas Collins. — 5th ed.
p. ; cm.
Includes index.
ISBN 978-1-4511-1825-4
1. Diagnosis, Differential. I. Title.
[DNLM: 1. Diagnosis, Differential. 2. Primary Health Care. WB 141.5]
RC71.5.C62 2012
616.07'5—dc23
2011020563
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10 9 8 7 6 5 4 3 2 1
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To my wife, Norie
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Preface
Over 30 years ago, I embarked on a mission to share with students and clinicians every-
where my approach to differential diagnosis. Today, I’m happy to say that for many of
you out there that mission has been fulfi lled.
The fi fth edition should be even more useful to you in the diagnosis of common
symptoms and signs. I have divided this edition into three sections. Section One is
devoted to the history and physical examination, particularly special examination tech-
niques for common symptoms and signs. Section Two applies my method of differential
diagnosis to an exhaustive list of symptoms and signs, as in previous editions. I have
carefully revised this section to include up-to-date diagnostic tests and expanded the
list of diagnostic possibilities where appropriate. Section Three is I believe unique to
textbooks of differential diagnosis. Here, I have explored common diseases that may be
a symptom of many other diseases. For example, you want to consult this section when
you have a case of diabetes mellitus or congestive heart failure that is not responding to
treatment.
Acknowledgments
I want to thank my wife, Norie, and her sister, Mildred Mendoza, for the excellent job
of typing this manuscript. I am grateful to Kerry Barrett, Product Manager, and Sonya
Seigafuse, Acquisitions Editor, for their diligent efforts in making the fi nished product
possible.
Finally, I thank the good Lord for the strength and wisdom he has provided me to
complete this project and look forward to writing the next edition.
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Contents
Preface iv
SECTION ONE
PART A: The Routine History and Physical Examination 1
The History 1
The Physical Examination 2
PART B: Special Clinical Examination Techniques for Common Symptoms and Signs 4
1. Pain 4
2. Lumps and Bumps 7
3. Bloody Discharge 8
4. Non Bloody Discharge 9
5. Functional Changes 10
SECTION TWO
Introduction 13
A
Abdominal Mass 17 Left Lower Quadrant Pain 38 Anorexia 55
Abdominal Mass, Generalized 17 Case Presentation #5 40 Anosmia or Unusual Odor 59
Right Upper Quadrant Mass 17 Epigastric Pain 40 Anuria and Oliguria 59
Case Presentation #1 20 Hypogastric Pain 44 Aphasia, Apraxia, and Agnosia 63
Left Upper Quadrant Mass 20 Absent or Diminished Pulse 46 Arm Pain 63
Right Lower Quadrant Mass 22 Acidosis (Decreased PH) 46 Case Presentation #6 66
Case Presentation #2 24 Acid Phosphatase Elevation 48 Aspartate Aminotransferase, A lanine
Left Lower Quadrant Mass 24 Alkaline Phosphatase Elevation 48 Aminotransferase, and Lactic
Epigastric Mass 25 Alkalosis (Increased PH) 48 Dehydrogenase Elevation 66
Case Presentation #3 27 Amnesia 50 Aural Discharge (Otorrhea) 66
Hypogastric Mass 27 Anal Mass 50 Auscultatory Signs of Pulmonary
Abdominal Pain 29 Anemia 50 Disease 68
Abdominal Pain, Generalized 29 Ankle Clonus and Hyperactive and Lung 68
Right Upper Quadrant Pain 31 Pathologic Refl exes 53 Heart 68
Left Upper Quadrant Pain 33 Cerebrum 54 Diseases of Other Organs 69
Case Presentation #4 33 Brainstem 55 Axillary Mass 69
Right Lower Quadrant Pain 35 Spinal Cord 55
B
Back Mass 72 Approach to the Diagnosis 76 Breast Discharge 80
Skin 72 Other Useful Tests 76 Approach to the Diagnosis 81
Subcutaneous Tissue and Fascia 72 Case Presentation #7 76 Other Useful Tests 81
Muscle 72 Blurred Vision, Blindness, and Breast Mass or Swelling 81
Bone 72 Scotomata 76 Approach to the Diagnosis 82
Retroperitoneal Structure 72 Approach to the Diagnosis 77 Other Useful Tests 82
Approach to the Diagnosis 72 Other Useful Tests 79 Breast Pain 82
Other Useful Tests 72 Case Presentation #8 79 Approach to the Diagnosis 84
Baldness 72 Bradycardia 79 Other Useful Tests 84
Approach to the Diagnosis 72 Approach to the Diagnosis 79
Bleeding Under the Skin 73 Other Useful Tests 79
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vi Contents
C
Cardiac Arrhythmias 85 Chills 96 Approach to the Diagnosis 106
Approach to the Diagnosis 85 Approach to the Diagnosis 96 Other Useful Tests 106
Other Useful Tests 85 Other Useful Tests 96 Case Presentation #11 106
Cardiomegaly 85 Chorea 96 Convulsions 108
Approach to the Diagnosis 90 Clubbing and Pulmonary Osteoar- Approach to the Diagnosis 111
Other Useful Tests 91 thropathy 97 Other Useful Tests 111
Cervical Bruit 92 Approach to the Diagnosis 100 Case Presentation #12 111
Approach to the Diagnosis 92 Other Useful Tests 100 Cough 112
Chest Pain 92 Coma and Somnolence 100 Approach to the Diagnosis 113
Approach to the Diagnosis 92 Approach to the Diagnosis 103 Other Useful Tests 114
Other Useful Tests 94 Other Useful Tests 104 Crepitus 116
Case Presentation #9 94 Case Presentation #10 104 Approach to the Diagnosis 116
Chest Wall Mass 94 Constipation 104 Cyanosis 116
Approach to the Diagnosis 95 Approach to the Diagnosis 106 Approach to the Diagnosis 117
Other Useful Tests 95 Other Useful Tests 106 Other Useful Tests 117
Constricted Pupils (Miosis) 106
D
Dandruff 118 Case Presentation #15 128 Approach to the Diagnosis 138
Decreased Respirations, Apnea, and Diffi culty Swallowing (Dysphagia) 128 Dysarthria and Speech Disorders 138
Cheyne–Stokes Breathing 118 Approach to the Diagnosis 130 Approach to the Diagnosis 140
Approach to the Diagnosis 118 Other Useful Tests 130 Other Useful Tests 140
Delayed Puberty 119 Diffi culty Urinating 130 Dysmenorrhea (See also Premenstrual
Approach to the Diagnosis 121 Approach to the Diagnosis 130 Syndrome) 140
Other Useful Tests 121 Other Useful Tests 130 Approach to the Diagnosis 140
Delirium 121 Dilated Pupils (Mydriasis) 131 Other Useful Tests 140
Approach to the Diagnosis 121 Approach to the Diagnosis 131 Dyspareunia 140
Other Useful Tests 121 Other Useful Tests 131 Approach to the Diagnosis 142
Case Presentation #13 122 Case Presentation #16 131 Other Useful Tests 142
Delusions 122 Dizziness 131 Dyspnea, Tachypnea, and Orthopnea
Approach to the Diagnosis 122 Approach to the Diagnosis 134 142
Depression, Anxiety, and Other Abnor- Other Useful Tests 135 Approach to the Diagnosis 144
mal Psychic States 122 Case Presentation #17 135 Other Useful Tests 146
Approach to the Diagnosis 124 Double Vision 135 Case Presentation #19 146
Case Presentation #14 125 Approach to the Diagnosis 135
Diarrhea, Acute 125 Other Useful Tests 137 Dystocia 146
Approach to the Diagnosis 125 Case Presentation #18 137 Approach to the Diagnosis 148
Other Useful Tests 125 Drop Attacks 137 Dysuria 148
Diarrhea, Chronic 125 Approach to the Diagnosis 137 Approach to the Diagnosis 148
Approach to the Diagnosis 128 Other Useful Tests 137 Other Useful Tests 148
Other Useful Tests 128 Dwarfi sm 137 Case Presentation #20 148
E
Earache 149 Other Useful Tests 155 Exophthalmos 158
Approach to the Diagnosis 149 Epiphora 155 Approach to the Diagnosis 161
Other Useful Tests 149 Approach to the Diagnosis 155 Extremity, Hand, and Foot Deformities
Edema of the Extremities 149 Epistaxis 155 161
Approach to the Diagnosis 149 Other Useful Tests 155 Approach to the Diagnosis 161
Other Useful Tests 150 Case Presentation #22 155 Extremity Mass 161
Case Presentation #21 150 Euphoria 157 Approach to the Diagnosis 163
Elbow Pain 150 Approach to the Diagnosis 158 Other Useful Tests 164
Approach to the Diagnosis 152 Excessive Sweating 158 Eye Pain 164
Other Useful Tests 152 Approach to the Diagnosis 158 Approach to the Diagnosis 165
Enuresis (Bedwetting) 152 Other Useful Tests 158 Other Useful Tests 165
Approach to the Diagnosis 154 Case Presentation #23 158 Case Presentation #24 165
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Contents vii
F
Face Mass 166 Fever 171 Flushed Face (Plethora) 181
Approach to the Diagnosis 166 Approach to the Diagnosis 173 Approach to the Diagnosis 181
Other Useful Tests 166 Other Useful Tests 175 Other Useful Tests 181
Facial Pain 166 Case Presentation #27 175 Case Presentation #31 181
Approach to the Diagnosis 166 Flank Mass 175 Foot, Heel, and Toe Pain 182
Other Useful Tests 166 Approach to the Diagnosis 175 Approach to the Diagnosis 184
Case Presentation #25 167 Other Useful Tests 176 Other Useful Tests 184
Facial Paralysis 167 Case Presentation #28 176 Case Presentation #32 184
Approach to the Diagnosis 168 Flank Pain 177 Forehead Enlargement 185
Other Useful Tests 169 Approach to the Diagnosis 179 Approach to the Diagnosis 185
Case Presentation #26 169 Other Useful Tests 179 Frequency and Urgency of
Facies, Abnormal 169 Case Presentation #29 179 Urination 185
Approach to the Diagnosis 169 Flashes of Light 179 Approach to the Diagnosis 185
Failure to Thrive 169 Approach to the Diagnosis 179 Other Useful Tests 185
Approach to the Diagnosis 169 Flatulence and Borborygmi 179 Case Presentation #33 185
Other Useful Tests 170 Approach to the Diagnosis 180 Frigidity 185
Fasciculations 171 Other Useful Tests 181 Approach to the Diagnosis 187
Approach to the Diagnosis 171 Case Presentation #30 181 Other Useful Tests 187
Other Useful Tests 171
G
Gait Disturbances 188 Girdle Pain 190 Groin Pain 193
Approach to the Diagnosis 188 Approach to the Diagnosis 191 Approach to the Diagnosis 194
Other Useful Tests 188 Glycosuria 192 Other Useful Tests 195
Case Presentation #34 190 Approach to the Diagnosis 192 Case Presentation #36 197
Gangrene 190 Other Useful Tests 192 Gynecomastia 197
Approach to the Diagnosis 190 Groin Mass 192 Approach to the Diagnosis 197
Gigantism 190 Approach to the Diagnosis 192 Other Useful Tests 197
Approach to the Diagnosis 190 Other Useful Tests 192 Case Presentation #37 197
Other Useful Tests 190 Case Presentation #35 192
H
Halitosis and other Breath Odors 198 Other Useful Tests 213 Case Presentation #45 225
Approach to the Diagnosis 198 Case Presentation #41 213 Hip Pain 226
Hallucinations 198 Hematuria 214 Approach to the Diagnosis 227
Approach to the Diagnosis 198 Approach to the Diagnosis 214 Other Useful Tests 227
Hand and Finger Pain 198 Other Useful Tests 214 Case Presentation #46 228
Approach to the Diagnosis 203 Hemianopsia 218 Hirsutism 228
Other Useful Tests 203 Approach to the Diagnosis 218 Approach to the Diagnosis 228
Case Presentation #38 203 Other Useful Tests 218 Other Useful Tests 229
Headaches 203 Case Presentation #42 218 Case Presentation #47 230
Approach to the Diagnosis 206 Hemiplegia 218 Hoarseness 230
Other Useful Tests 206 Approach to the Diagnosis 218 Approach to the Diagnosis 230
Case Presentation #39 206 Other Useful Tests 219 Other Useful Tests 230
Head Deformities 206 Hemoptysis 219 Case Presentation #48 230
Approach to the Diagnosis 207 Approach to the Diagnosis 220 Horner Syndrome 230
Other Useful Tests 208 Other Useful Tests 220 Approach to the Diagnosis 232
Head Mass 208 Case Presentation #43 220 Other Useful Tests 232
Approach to the Diagnosis 208 Hepatomegaly 220 Hypercalcemia 232
Heartburn 208 Approach to the Diagnosis 222 Approach to the Diagnosis 234
Approach to the Diagnosis 208 Other Useful Tests 224 Other Useful Tests 234
Other Useful Tests 208 Case Presentation #44 225 Hypercholesterolemia 234
Case Presentation #40 208 Hiccoughs 225 Approach to the Diagnosis 234
Hematemesis and Melena 208 Approach to the Diagnosis 225 Other Useful Tests 234
Approach to the Diagnosis 211 Other Useful Tests 225 Hyperglycemia 234
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viii Contents
Approach to the Diagnosis 234 Hypoactive Refl exes 242 Approach to the Diagnosis 252
Other Useful Tests 235 Approach to the Diagnosis 244 Case Presentation #52 252
Hyperkalemia 236 Other Useful Tests 244 Hyponatremia 252
Approach to the Diagnosis 237 Case Presentation #51 244 Approach to the Diagnosis 253
Other Useful Tests 237 Hypoalbuminemia 244 Other Useful Tests 253
Hypermenorrhea 237 Approach to the Diagnosis 245 Hypotension and Shock 253
Approach to the Diagnosis 237 Other Useful Tests 245 Approach to the Diagnosis 256
Case Presentation #49 237 Hypocalcemia 246 Other Useful Tests 256
Hypernatremia 237 Approach to the Diagnosis 246 Case Presentation #53 256
Approach to the Diagnosis 237 Other Useful Tests 246 Hypotension, Orthostatic 256
Hypertension 238 Hypoglycemia 247 Approach to the Diagnosis 256
Approach to the Diagnosis 239 Approach to the Diagnosis 248 Hypothermia 256
Other Useful Tests 239 Other Useful Tests 249 Approach to the Diagnosis 257
Case Presentation #50 240 Hypokalemia 250 Other Useful Tests 257
Hypertriglyceridemia 240 Approach to the Diagnosis 250 Hypoxemia 258
Approach to the Diagnosis 240 Other Useful Tests 250 Approach to the Diagnosis 259
Other Useful Tests 241 Hypomenorrhea and Amenorrhea 250 Other Useful Tests 259
I
Impotence 260 Other Useful Tests 263 Other Useful Tests 266
Approach to the Diagnosis 260 Case Presentation #55 263 Case Presentation #57 266
Other Useful Tests 260 Indigestion 264 Insomnia 266
Case Presentation #54 262 Approach to the Diagnosis 264 Approach to the Diagnosis 269
Incontinence, Fecal 262 Other Useful Tests 264 Other Useful Tests 269
Approach to the Diagnosis 262 Case Presentation #56 264 Case Presentation #58 269
Incontinence, Urinary 262 Infertility 264 Intracranial Bruit 270
Approach to the Diagnosis 262 Approach to the Diagnosis 266 Approach to the Diagnosis 270
J
Jaundice 271 Jaw Swelling 274 Joint Swelling 277
Approach to the Diagnosis 271 Approach to the Diagnosis 274 Approach to the Diagnosis 277
Other Useful Tests 271 Joint Pain 274 Other Useful Tests 280
Case Presentation #59 272 Approach to the Diagnosis 274 Case Presentation #61 280
Jaw Pain 272 Other Useful Tests 277
Approach to the Diagnosis 272 Case Presentation #60 277
K
Knee Pain 281 Knee Swelling 281 Kyphosis 282
Approach to the Diagnosis 281 Approach to the Diagnosis 282 Approach to the Diagnosis 282
Other Useful Tests 281 Other Useful Tests 282
L
Leg Pain 283 Leukopenia 288 Approach to the Diagnosis 291
Approach to the Diagnosis 283 Approach to the Diagnosis 288 Other Useful Tests 292
Other Useful Tests 283 Other Useful Tests 288 Case Presentation #63 292
Case Presentation #62 285 Lip Swelling 288 Lymphadenopathy, Generalized 292
Leukocytosis 285 Approach to the Diagnosis 288 Approach to the Diagnosis 292
Approach to the Diagnosis 287 Lordosis 288 Other Useful Tests 294
Other Useful Tests 288 Low Back Pain 288 Case Presentation #64 294
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Contents ix
M
Memory Loss and Dementia 295 Monoplegia 298 Case Presentation #66 303
Approach to the Diagnosis 295 Approach to the Diagnosis 298 Muscular Cramps 303
Other Useful Tests 295 Mouth Pigmentation 298 Approach to the Diagnosis 304
Case Presentation #65 295 Approach to the Diagnosis 299 Other Useful Tests 304
Menstrual Cramps 297 Other Useful Tests 299 Case Presentation #67 304
Approach to the Diagnosis 297 Murmurs 299 Musculoskeletal Pain, Generalized 304
Meteorism 297 Approach to the Diagnosis 299 Approach to the Diagnosis 306
Approach to the Diagnosis 297 Muscular Atrophy 299 Other Useful Tests 306
Other Useful Tests 297 Approach to the Diagnosis 301 Case Presentation #68 306
Miscellaneous Sites of Bleeding 297 Other Useful Tests 301 Myoclonus 306
N
Nail Changes 307 Other Useful Tests 310 Nightmares 319
Approach to the Diagnosis 307 Nausea and Vomiting 310 Approach to the Diagnosis 319
Other Useful Tests 307 Approach to the Diagnosis 314 Nocturia 319
Nasal Discharge 307 Other Useful Tests 314 Approach to the Diagnosis 319
Approach to the Diagnosis 309 Neck Mass 314 Nose, Regurgitation of Food
Other Useful Tests 309 Approach to the Diagnosis 314 Through 320
Nasal Mass or Swelling 310 Other Useful Tests 315 Approach to the Diagnosis 321
Approach to the Diagnosis 310 Neck Pain 317 Nuchal Rigidity 321
Other Useful Tests 310 Approach to the Diagnosis 318 Approach to the Diagnosis 322
Nasal Obstruction 310 Other Useful Tests 319 Nystagmus 322
Approach to the Diagnosis 310 Case Presentation #69 319 Approach to the Diagnosis 323
O
Obesity 324 Oral or Lingual Mass 324 Other Useful Tests 327
Approach to the Diagnosis 324 Approach to the Diagnosis 324 Orbital Mass 327
Other Useful Tests 324 Orbital Discharge 325
Case Presentation #70 324 Approach to the Diagnosis 327
P
Pallor of the Face, Nails, or Other Useful Tests 340 Approach to the Diagnosis 350
Conjunctiva 328 Penile Sores 341 Other Useful Tests 350
Approach to the Diagnosis 328 Approach to the Diagnosis 342 Prostatic Mass or Enlargement 351
Other Useful Tests 328 Periorbital and Facial Edema 342 Approach to the Diagnosis 353
Palpitations 328 Photophobia 342 Other Useful Tests 353
Approach to the Diagnosis 328 Approach to the Diagnosis 342 Proteinuria 353
Other Useful Tests 329 Polycythemia 342 Approach to the Diagnosis 353
Case Presentation #71 331 Approach to the Diagnosis 342 Other Useful Tests 353
Papilledema 331 Other Useful Tests 342 Pruritus 353
Approach to the Diagnosis 331 Polydipsia 343 Approach to the Diagnosis 356
Other Useful Tests 331 Approach to the Diagnosis 345 Other Useful Tests 356
Paresthesias, Dysesthesias, and Other Useful Tests 345 Ptosis 356
Numbness 331 Case Presentation #73 345 Approach to the Diagnosis 356
Approach to the Diagnosis 334 Polyphagia 345 Other Useful Tests 356
Other Useful Tests 334 Approach to the Diagnosis 345 Ptyalism 356
Case Presentation #72 334 Case Presentation #74 345 Approach to the Diagnosis 357
Pelvic Mass 334 Polyuria 345 Pulsatile Mass 357
Approach to the Diagnosis 337 Approach to the Diagnosis 348 Approach to the Diagnosis 359
Other Useful Tests 338 Other Useful Tests 348 Pulse Rhythm Abnormalities 359
Pelvic Pain 338 Case Presentation #75 348 Approach to the Diagnosis 359
Approach to the Diagnosis 338 Popliteal Swelling 348 Pyuria 359
Other Useful Tests 338 Approach to the Diagnosis 348 Approach to the Diagnosis 359
Penile Pain 339 Other Useful Tests 348 Other Useful Tests 361
Approach to the Diagnosis 340 Priapism 349
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