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Symptoms and Signs – Differential Diagnosis of Raised in Acid phosphatase
Lysosomal storage disease, e.g. Gaucher's disease
Paget's disease of bone
Prostate cancer
Thrombocythaemia
Lysosomal storage disease, e.g. Gaucher's disease
Paget's disease of bone
Prostate cancer
Thrombocythaemia
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Symptoms and Signs – Differential Diagnosis of Acidosis
Normal anion gap
Reduced HCO3 GI loss: diarrhoea, fistula (biliary, intestinal, pancreatic), ileostomy,
ureterosigmoidostomy
Renal loss: renal tubular acidosis (type 2), renal tubular damage (e.g. drugs/
heavy metals), hyperparathyroidism, acetazolamide
Inceased H+ Renal tubular acidosis (1 & 4), ammonium chloride ingestion)
High anion gap
Ketoacidosis: diabetes mellitus, excess alcohol, starvation
Lactic acidosis:
Tissue hypoxia, e.g. shock (haemorrhagidseptic), severe exercise, severe
anaemia
Drugs: metformin, ethanol, methanol, ethylene glycol, zidovudine
D-Lactic acidosis (short gut syndrome)
Leukaemia
Lymphoma
Liver failure
Glucose-6-phosphatase deficiency, mitochondrial disorders (e.g. MELAS)
Renal failure
Salicylate poisoning
Respiratory
CNS
Organic disease involving respiratory centre (e.g. vascular, infection,
inflammation, trauma, tumour)
Drugs: opiates, benzodiazepines, barbiturates and other anaesthetic agents
Lungs
Severe asthma (uncommonly), COPD, large airway obstruction, obstructive sleep apnoea
Neuromuscular
Motor neurones: Guillain-Barre syndrome, motor neurone disease, poliomyelitis, acute porphyria
Neuromuscular junction/muscle: myasthenia gravis, muscular dystrophies, muscle
relaxants, diaphagmatic paralysis
Chest wall
Severe kyphoscoliosis, severe obesity, traumatic 'flail chest'
Normal anion gap
Reduced HCO3 GI loss: diarrhoea, fistula (biliary, intestinal, pancreatic), ileostomy,
ureterosigmoidostomy
Renal loss: renal tubular acidosis (type 2), renal tubular damage (e.g. drugs/
heavy metals), hyperparathyroidism, acetazolamide
Inceased H+ Renal tubular acidosis (1 & 4), ammonium chloride ingestion)
High anion gap
Ketoacidosis: diabetes mellitus, excess alcohol, starvation
Lactic acidosis:
Tissue hypoxia, e.g. shock (haemorrhagidseptic), severe exercise, severe
anaemia
Drugs: metformin, ethanol, methanol, ethylene glycol, zidovudine
D-Lactic acidosis (short gut syndrome)
Leukaemia
Lymphoma
Liver failure
Glucose-6-phosphatase deficiency, mitochondrial disorders (e.g. MELAS)
Renal failure
Salicylate poisoning
Respiratory
CNS
Organic disease involving respiratory centre (e.g. vascular, infection,
inflammation, trauma, tumour)
Drugs: opiates, benzodiazepines, barbiturates and other anaesthetic agents
Lungs
Severe asthma (uncommonly), COPD, large airway obstruction, obstructive sleep apnoea
Neuromuscular
Motor neurones: Guillain-Barre syndrome, motor neurone disease, poliomyelitis, acute porphyria
Neuromuscular junction/muscle: myasthenia gravis, muscular dystrophies, muscle
relaxants, diaphagmatic paralysis
Chest wall
Severe kyphoscoliosis, severe obesity, traumatic 'flail chest'
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Symptoms and Signs – Differential Diagnosis of Ageusia
Chorda tympani injury, e.g. during surgery (unilateral anterior 2/3 of the tongue)
Infection/inflammatory diseases of oral cavity
Radiation
Chorda tympani injury, e.g. during surgery (unilateral anterior 2/3 of the tongue)
Infection/inflammatory diseases of oral cavity
Radiation
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Symptoms and Signs – Differential Diagnosis of Alkalosis
Metabolic
GI loss of H+
Vomiting, laxative abuse, villous adenoma, VIPoma
Renal loss of H+
Increased Mineralocorticoid activity (stimulates H+ secretion):
Hyperaldosteronism
Increased Glucocorticoids: Cushing's syndrome, liquorice (inhibits 11-hydroxysteroid
dehydrogenase and reduced glucocorticoid metabolism)
increased Na+ delivery to distal nephron
Diuretics: thiazides and loop diuretics (also increased aldosterone secretion)
Bartter's syndrome, Gitelman's syndrome
Intracellular shift of H+
Hypokalaemia (also note that the above causes of GI/renal loss of H+, also induce
K+ loss)
Other
Compensation for respiratory acidosis
Excessive alkali ingestion (e.g. increased sodium bicarbonate administration in treatment
of acidotic states)
Fulminant hepatic failure (failure to synthesize urea and neutralize bicarbonate
derived from amino acid metabolism)
Respiratory
Hyperventilation:
Physiological (anxiety, pain, fever, pregnancy, high altitude
Mechanical overventilation
Respiratory failure (type I): asthma, COPD, pneumonia, pulmonary oedema,
pulmonary embolism, ARDS, fibrosing alveolitis, right -, left shunt
Salicylate poisoning, CO poisoning
CNS disease (CVA, infection, tumour, trauma)
Others: liver failure (acute), Gram -ve septicaemia
Metabolic
GI loss of H+
Vomiting, laxative abuse, villous adenoma, VIPoma
Renal loss of H+
Increased Mineralocorticoid activity (stimulates H+ secretion):
Hyperaldosteronism
Increased Glucocorticoids: Cushing's syndrome, liquorice (inhibits 11-hydroxysteroid
dehydrogenase and reduced glucocorticoid metabolism)
increased Na+ delivery to distal nephron
Diuretics: thiazides and loop diuretics (also increased aldosterone secretion)
Bartter's syndrome, Gitelman's syndrome
Intracellular shift of H+
Hypokalaemia (also note that the above causes of GI/renal loss of H+, also induce
K+ loss)
Other
Compensation for respiratory acidosis
Excessive alkali ingestion (e.g. increased sodium bicarbonate administration in treatment
of acidotic states)
Fulminant hepatic failure (failure to synthesize urea and neutralize bicarbonate
derived from amino acid metabolism)
Respiratory
Hyperventilation:
Physiological (anxiety, pain, fever, pregnancy, high altitude
Mechanical overventilation
Respiratory failure (type I): asthma, COPD, pneumonia, pulmonary oedema,
pulmonary embolism, ARDS, fibrosing alveolitis, right -, left shunt
Salicylate poisoning, CO poisoning
CNS disease (CVA, infection, tumour, trauma)
Others: liver failure (acute), Gram -ve septicaemia
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Symptoms and Signs – Differential Diagnosis of Alopecia
Non-scarring
Traction, trichotillomania
Telogen effluvium: transitory j in number of hairs in resting phase of the hair growth cycle, associated with stress, (e.g. surgery, febrile illness, childbirth, etc.)
Nutritional deficiency (iron, zinc, biotin, caloric deficiency)
Endocrine diseases (hypopituitarism, hypo/hyperthyroidism, diabetes mellitus)
Drugs (cytotoxics, ciclosporin, OCPs, anticoagulants, antithyroid drugs, vitamin A/ retinoids)
Cutaneous diseases (e.g. psoriasis, eczema)
Congenital
Alopecia areata
Aging (male/female pattern baldness)
Scarring
Infection: pyogenic infection, TB (lupus vulgaris), syphilis, viral (varicella, herpes simplex), fungal (e.g. ringworm), protozoa! (Leishmaniasis), leprosy
Inflammatory disease: SLE, scleroderma, sarcoidosis
Skin disease: lichen planus, cicatricial pemphigoid, necrobiosis lipoidica, folliculitis decalvans
Trauma/burns
Non-scarring
Traction, trichotillomania
Telogen effluvium: transitory j in number of hairs in resting phase of the hair growth cycle, associated with stress, (e.g. surgery, febrile illness, childbirth, etc.)
Nutritional deficiency (iron, zinc, biotin, caloric deficiency)
Endocrine diseases (hypopituitarism, hypo/hyperthyroidism, diabetes mellitus)
Drugs (cytotoxics, ciclosporin, OCPs, anticoagulants, antithyroid drugs, vitamin A/ retinoids)
Cutaneous diseases (e.g. psoriasis, eczema)
Congenital
Alopecia areata
Aging (male/female pattern baldness)
Scarring
Infection: pyogenic infection, TB (lupus vulgaris), syphilis, viral (varicella, herpes simplex), fungal (e.g. ringworm), protozoa! (Leishmaniasis), leprosy
Inflammatory disease: SLE, scleroderma, sarcoidosis
Skin disease: lichen planus, cicatricial pemphigoid, necrobiosis lipoidica, folliculitis decalvans
Trauma/burns
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Symptoms and Signs – Differential Diagnosis of Amenorrhoea
Non-pathological: pregnancy, lactation, menopause, drugs (e.g. Depo-Provera)
Hypothalamus: starvation, anorexia, excessive exercise, weight loss, GnRH
deficiency (isolated or part of Kallmann's syndrome)
Pituitary: hypopituitarism, hyperprolactinaemia
Ovaries: PCOS, premature ovarian failure, damage to ovaries (infection e.g.
mumps, autoimmune, surgery, radiotherapy), ovarian dysgensis (e.g. Turner's
syndrome)
Uterus/vagina: absent uterus, imperforate hymen, transverse vaginal septum
Asherman's syndrome: scarring of endometrial lining 2° to infection and
instrumentation, e.g. D&C
Thyroid: hypo/hyperthyroidism
Adrenals: adrenal tumours, Cushing's syndrome
Note: The causes in italics present only with primary amenorrhoea.
Non-pathological: pregnancy, lactation, menopause, drugs (e.g. Depo-Provera)
Hypothalamus: starvation, anorexia, excessive exercise, weight loss, GnRH
deficiency (isolated or part of Kallmann's syndrome)
Pituitary: hypopituitarism, hyperprolactinaemia
Ovaries: PCOS, premature ovarian failure, damage to ovaries (infection e.g.
mumps, autoimmune, surgery, radiotherapy), ovarian dysgensis (e.g. Turner's
syndrome)
Uterus/vagina: absent uterus, imperforate hymen, transverse vaginal septum
Asherman's syndrome: scarring of endometrial lining 2° to infection and
instrumentation, e.g. D&C
Thyroid: hypo/hyperthyroidism
Adrenals: adrenal tumours, Cushing's syndrome
Note: The causes in italics present only with primary amenorrhoea.
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Symptoms and Signs – Differential Diagnosis of Amnesia
Acute/transient
In the presence of other cognitive deficits: acute confusional state (See Delirium)
Temporal lobe epilepsy
Transient global amnesia (may be associated with migraine)
Trauma (head injury)
Acute/transient
In the presence of other cognitive deficits: acute confusional state (See Delirium)
Temporal lobe epilepsy
Transient global amnesia (may be associated with migraine)
Trauma (head injury)
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Symptoms and Signs – Differential Diagnosis of Migraine
Chronic/persistent
In the presence of other cognitive deficits
Infection: herpes simplex encephalitis
Inflammation: limbic encephalitis (may be paraneoplastic), sarcoidosis
Medial temporal lobe lesions (bilateral)
Toxic metabolic: thiamine deficiency (Korsakoff's psychosis in alcoholism, hyperemesis gravidarum)
Transient ischaemic attack (TIA), tumours (rare)
Tumours: midline (in the region of the third ventricle)
Vascular: posterior cerebral artery occlusion (bilateral)
Chronic/persistent
In the presence of other cognitive deficits
Infection: herpes simplex encephalitis
Inflammation: limbic encephalitis (may be paraneoplastic), sarcoidosis
Medial temporal lobe lesions (bilateral)
Toxic metabolic: thiamine deficiency (Korsakoff's psychosis in alcoholism, hyperemesis gravidarum)
Transient ischaemic attack (TIA), tumours (rare)
Tumours: midline (in the region of the third ventricle)
Vascular: posterior cerebral artery occlusion (bilateral)
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Symptoms and Signs – Differential Diagnosis of Epigastric Abdominal Pain
Acute gastritis
Functional disorders: non-ulcer dyspepsia, irritable bowel syndrome
Malignancy: gastric, pancreatic
Pain from adjacent areas: central abdominal pain, cardiadpulmonary/ pleural pathology, e.g. Ml, pericarditis, pneumonia
Pancreatitis
Peptic ulcer
Reflux oesophagitis
Acute gastritis
Functional disorders: non-ulcer dyspepsia, irritable bowel syndrome
Malignancy: gastric, pancreatic
Pain from adjacent areas: central abdominal pain, cardiadpulmonary/ pleural pathology, e.g. Ml, pericarditis, pneumonia
Pancreatitis
Peptic ulcer
Reflux oesophagitis
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Symptoms and Signs – Differential Diagnosis of Right upper quadrant (RUQ) Abdominal Pain
Appendicitis, e.g. in a pregnant woman
Colonic cancer (hepatic flexure)
Gall bladder pathology: cholecystitis (usually related to gallstones, occasionally may be acalculous), biliary colic, cholangitis
Herpes zoster
Liver pathology: hepatitis, hepatomegaly (congestive, e.g. in congestive cardiac failure, Budd-Chiari syndrome), hepatic tumours, hepatidsubphrenic abscess
Pain from adjacent areas: See Epigastric (e.g. pancreatitis, peptic ulcer), RIF, Loin pain, pulmonary/pleural pathology, e.g. pneumonia, pulmonary infarction
Appendicitis, e.g. in a pregnant woman
Colonic cancer (hepatic flexure)
Gall bladder pathology: cholecystitis (usually related to gallstones, occasionally may be acalculous), biliary colic, cholangitis
Herpes zoster
Liver pathology: hepatitis, hepatomegaly (congestive, e.g. in congestive cardiac failure, Budd-Chiari syndrome), hepatic tumours, hepatidsubphrenic abscess
Pain from adjacent areas: See Epigastric (e.g. pancreatitis, peptic ulcer), RIF, Loin pain, pulmonary/pleural pathology, e.g. pneumonia, pulmonary infarction
