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Symptoms and Signs – Differential Diagnosis of Coma in Pediatric Cases
ANOXIA
• Birth asphyxia
• Carbon monoxide (CO) poisoning
• Croup/epiglottitis
• Meconium aspiration
INFECTION
• Hemolysis
• Blood loss
• Hydrops fetalis
• Meningoencephalitis
• Sepsis
• Postimmunization encephalitis
INCREASED INTRACRANIAL PRESSURE
• Anoxia
• Inborn metabolic errors
• Toxic encephalopathy
• Reye’s syndrome
• Head trauma/intracranial bleed
• Hydrocephalus
• Posterior fossa tumors
HYPERTENSIVE ENCEPHALOPATHY
• Coarctation of aorta
• Nephritis
• Vasculitis
• Pheochromocytoma
ISCHEMIA
• Hypoplastic left side of heart
• Shunting lesions
• Aortic stenosis
• Cardiovascular collapse (any cause)
PURPURIC CAUSES
• Disseminated intravascular coagulation
• Hemolytic-uremic syndrome
• Leukemia
• Thrombotic purpura
HYPERCAPNIA
• Cystic fibrosis
• Bronchopulmonary dysplasia
• Congenital lung anomalies
NEOPLASM
• Medulloblastoma
• Glioma of brainstem
• Posterior fossa tumors
DRUGS/TOXINS
• Maternal sedation
• Alcohol
• Any drug
• Lead
• Salicylism
• Arsenic
• Pesticides
ELECTROLYTE ABNORMALITIES
• Hypernatremia (diarrhea, dehydration, salt poisoning)
• Hyponatremia (syndrome of inappropriate antidiuretic hormone [SIADH], androgenital syndrome, gastroenteritis)
• Hyperkalemia (renal failure, salicylism, androgenitalism)
• Hypokalemia (diarrhea, hyperaldosteronism, salicylism, diabetic ketoacidosis [DKA])
• Hypocalcemia (vitamin D deficiency, hyperparathyroidism)
• Severe acidosis (sepsis, cold injury, salicylism, DKA)
HYPOGLYCEMIA
• Birth injury or stress
• Diabetes
• Alcohol
• Salicylism
• Hyperinsulinemia
• Iatrogenic
POSTSEIZURE
• Renal causes: nephritis, hypoplastic kidneys
• Hepatic causes: acute hepatitis, fulminant hepatic failure, inborn metabolic errors, bile duct atresia
ANOXIA
• Birth asphyxia
• Carbon monoxide (CO) poisoning
• Croup/epiglottitis
• Meconium aspiration
INFECTION
• Hemolysis
• Blood loss
• Hydrops fetalis
• Meningoencephalitis
• Sepsis
• Postimmunization encephalitis
INCREASED INTRACRANIAL PRESSURE
• Anoxia
• Inborn metabolic errors
• Toxic encephalopathy
• Reye’s syndrome
• Head trauma/intracranial bleed
• Hydrocephalus
• Posterior fossa tumors
HYPERTENSIVE ENCEPHALOPATHY
• Coarctation of aorta
• Nephritis
• Vasculitis
• Pheochromocytoma
ISCHEMIA
• Hypoplastic left side of heart
• Shunting lesions
• Aortic stenosis
• Cardiovascular collapse (any cause)
PURPURIC CAUSES
• Disseminated intravascular coagulation
• Hemolytic-uremic syndrome
• Leukemia
• Thrombotic purpura
HYPERCAPNIA
• Cystic fibrosis
• Bronchopulmonary dysplasia
• Congenital lung anomalies
NEOPLASM
• Medulloblastoma
• Glioma of brainstem
• Posterior fossa tumors
DRUGS/TOXINS
• Maternal sedation
• Alcohol
• Any drug
• Lead
• Salicylism
• Arsenic
• Pesticides
ELECTROLYTE ABNORMALITIES
• Hypernatremia (diarrhea, dehydration, salt poisoning)
• Hyponatremia (syndrome of inappropriate antidiuretic hormone [SIADH], androgenital syndrome, gastroenteritis)
• Hyperkalemia (renal failure, salicylism, androgenitalism)
• Hypokalemia (diarrhea, hyperaldosteronism, salicylism, diabetic ketoacidosis [DKA])
• Hypocalcemia (vitamin D deficiency, hyperparathyroidism)
• Severe acidosis (sepsis, cold injury, salicylism, DKA)
HYPOGLYCEMIA
• Birth injury or stress
• Diabetes
• Alcohol
• Salicylism
• Hyperinsulinemia
• Iatrogenic
POSTSEIZURE
• Renal causes: nephritis, hypoplastic kidneys
• Hepatic causes: acute hepatitis, fulminant hepatic failure, inborn metabolic errors, bile duct atresia
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Symptoms and Signs – Differential Diagnosis of Condyloma Acuminatum
• Verrucous carcinoma
• Syphilis
• Seborrheic keratosis
• Lichen planus
• Erythroplasia of Queyrat
• Dysplastic warts
• Bowenoid papulosis
• Abnormal anatomic variants or skin tags around labia minora and introitus, pearly penile papules
• Verrucous carcinoma
• Syphilis
• Seborrheic keratosis
• Lichen planus
• Erythroplasia of Queyrat
• Dysplastic warts
• Bowenoid papulosis
• Abnormal anatomic variants or skin tags around labia minora and introitus, pearly penile papules
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Symptoms and Signs – Differential Diagnosis of Congenital Adrenal Hyperplasia
• Addison’s disease
• Adrenocortical carcinoma
• Androgen resistance syndromes
• Leydig cell tumors
• Mixed gonadal dysgenesis
• Pituitary adenoma
• Polycystic ovary syndrome
• Precocious puberty
• Pseudohermaphroditism
• Testicular carcinoma
• Addison’s disease
• Adrenocortical carcinoma
• Androgen resistance syndromes
• Leydig cell tumors
• Mixed gonadal dysgenesis
• Pituitary adenoma
• Polycystic ovary syndrome
• Precocious puberty
• Pseudohermaphroditism
• Testicular carcinoma
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Symptoms and Signs – Differential Diagnosis of Congestive Heart Failure
• Venous occlusive disease
• Pulmonary embolism
• Pneumonia
• Nephrotic syndrome
• Hypothyroidism
• Heroin overdose
• Cirrhosis
• Chronic obstructive pulmonary disease (COPD), asthma
• Acute respiratory distress syndrome (ARDS)
• Venous occlusive disease
• Pulmonary embolism
• Pneumonia
• Nephrotic syndrome
• Hypothyroidism
• Heroin overdose
• Cirrhosis
• Chronic obstructive pulmonary disease (COPD), asthma
• Acute respiratory distress syndrome (ARDS)
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Symptoms and Signs – Differential Diagnosis of Conjunctival Neoplasm
MALIGNANT
• Squamous cell carcinoma
• Melanoma
• Sebaceous carcinoma
• Kaposi’s sarcoma
• Metastatic neoplasms
BENIGN
• Melanocytic nevus
• Squamous papilloma
• Hemangioma
• Lymphangioma
• Myxoma
MALIGNANT
• Squamous cell carcinoma
• Melanoma
• Sebaceous carcinoma
• Kaposi’s sarcoma
• Metastatic neoplasms
BENIGN
• Melanocytic nevus
• Squamous papilloma
• Hemangioma
• Lymphangioma
• Myxoma
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Symptoms and Signs – Differential Diagnosis of Conjunctivitis
• Acute glaucoma
• Acute iritis
• Canalicular obstruction
• Corneal lesions
• Episcleritis
• Scleritis
• Uveitis
• Acute glaucoma
• Acute iritis
• Canalicular obstruction
• Corneal lesions
• Episcleritis
• Scleritis
• Uveitis
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Symptoms and Signs – Differential Diagnosis of Constipation
• Volvulus
• Tuberculous stricture
• Strangulated femoral hernia
• Poor dietary habits: insufficient bulk in diet, inadequate fluid intake
• Painful anal conditions: hemorrhoids, fissure, stricture
• Irritable bowel syndrome, pregnancy, anorexia nervosa, depression
• Intussusception
• Intestinal obstruction
• Inflammatory bowel disease (IBD)
• Hypercalcemia or hypokalemia, uremia
• Hirschsprung’s disease, meconium ileus, congenital atresia in infants
• Hematoma of bowel wall, secondary to trauma or anticoagulants
• GI neoplasm
• Gallstone ileus
• Fecal impaction
• Drugs: codeine, morphine, antacids with aluminum, verapamil, anticonvulsants, anticholinergics, disopyramide, cholestyramine, alosetron, iron supplements
• Diverticular disease
• Decreased intestinal peristalsis: old age, spinal cord injuries, myxedema, diabetes, multiple sclerosis, parkinsonism and other neurologic diseases
• Change from daily routine: travel, hospital admission, physical inactivity
• Ameboma
• Adhesions
• Acute abdominal conditions: renal colic, salpingitis, biliary colic, appendicitis, ischemia
• Volvulus
• Tuberculous stricture
• Strangulated femoral hernia
• Poor dietary habits: insufficient bulk in diet, inadequate fluid intake
• Painful anal conditions: hemorrhoids, fissure, stricture
• Irritable bowel syndrome, pregnancy, anorexia nervosa, depression
• Intussusception
• Intestinal obstruction
• Inflammatory bowel disease (IBD)
• Hypercalcemia or hypokalemia, uremia
• Hirschsprung’s disease, meconium ileus, congenital atresia in infants
• Hematoma of bowel wall, secondary to trauma or anticoagulants
• GI neoplasm
• Gallstone ileus
• Fecal impaction
• Drugs: codeine, morphine, antacids with aluminum, verapamil, anticonvulsants, anticholinergics, disopyramide, cholestyramine, alosetron, iron supplements
• Diverticular disease
• Decreased intestinal peristalsis: old age, spinal cord injuries, myxedema, diabetes, multiple sclerosis, parkinsonism and other neurologic diseases
• Change from daily routine: travel, hospital admission, physical inactivity
• Ameboma
• Adhesions
• Acute abdominal conditions: renal colic, salpingitis, biliary colic, appendicitis, ischemia
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Symptoms and Signs – Differential Diagnosis of Adult Constipation
NO GROSS STRUCTURAL ABNORMALITY
• Inadequate fiber intake
• Irritable bowel syndrome (associated with abdominal pain) or
functional constipation
• Idiopathic slow-transit constipation
• “Obstructed defecation”: pelvic floor dysfunction (or dyssynergia)
STRUCTURAL DISORDERS
• Anal fissure, infection, or stenosis
• Colon cancer or stricture
• Aganglionosis or abnormal myenteric plexus
• Hirschsprung’s disease
• Chagas’ disease
• Neuropathic pseudo-obstruction
• Abnormal colonic muscle
• Myopathy
• Dystrophia myotonica
• Systemic sclerosis
• Idiopathic megarectum or megacolon
• Proximal megacolon
NEUROLOGIC CAUSES
• Diabetic autonomic neuropathy
• Damage to the sacral parasympathetic outflow
• Spinal cord damage or disease (e.g., multiple sclerosis)
• Parkinson’s disease
• Blunting of consciousness, mental retardation, psychosis
• Pain induced by straining (e.g., sciatic nerve compression)
ENDOCRINE OR METABOLIC CAUSES
• Hypothyroidism
• Hypercalcemia
• Porphyria
• Pregnancy
PSYCHOLOGICAL DISORDERS
• Depression
• Anorexia nervosa
• Denied bowel habit
DRUG SIDE EFFECTS
NO GROSS STRUCTURAL ABNORMALITY
• Inadequate fiber intake
• Irritable bowel syndrome (associated with abdominal pain) or
functional constipation
• Idiopathic slow-transit constipation
• “Obstructed defecation”: pelvic floor dysfunction (or dyssynergia)
STRUCTURAL DISORDERS
• Anal fissure, infection, or stenosis
• Colon cancer or stricture
• Aganglionosis or abnormal myenteric plexus
• Hirschsprung’s disease
• Chagas’ disease
• Neuropathic pseudo-obstruction
• Abnormal colonic muscle
• Myopathy
• Dystrophia myotonica
• Systemic sclerosis
• Idiopathic megarectum or megacolon
• Proximal megacolon
NEUROLOGIC CAUSES
• Diabetic autonomic neuropathy
• Damage to the sacral parasympathetic outflow
• Spinal cord damage or disease (e.g., multiple sclerosis)
• Parkinson’s disease
• Blunting of consciousness, mental retardation, psychosis
• Pain induced by straining (e.g., sciatic nerve compression)
ENDOCRINE OR METABOLIC CAUSES
• Hypothyroidism
• Hypercalcemia
• Porphyria
• Pregnancy
PSYCHOLOGICAL DISORDERS
• Depression
• Anorexia nervosa
• Denied bowel habit
DRUG SIDE EFFECTS
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Dermatology - Polymorphous light eruption (PMLE)
PMLE refers to a collection of diverse, unexplained, acquired, and recurring skin rashes that occur as a delayed response to exposure to UV radiation. Polymorphic light eruption (PMLE) is the prevailing form of photodermatitis, typically occurring in individuals during their third decade of life. Prevalence is higher among women compared to men, as well as among those with lighter skin. Actinic prurigo is a genetic condition found in American Indians in both North and South America.
Lesions manifest during the early spring and summer seasons, characterized by the presence of erythematous macules, papules, plaques, and vesicles. Nevertheless, in every case, the eruption consistently manifests as only one kind, most commonly papular or papulovesicular. PMLE often manifests shortly after exposure and persists for a duration of 7-10 days. Occasionally, towards the end of the summer, the eruptions cease to happen, indicating a process of solidification. The symptoms include pruritus (itching that may occur before the rash appears) and paresthesia (tingling sensation).
Abnormalities
The papular and papulovesicular forms are the most common. Plaques or urticarial plaques are far less frequent. The lesions have a color spectrum ranging from pink to red. The eruption often avoids locations that are regularly exposed (such as the face and neck) and is most commonly seen on the forearms, V area of the neck, arms, and chest. Lesions may also manifest on the face in the absence of prior sun exposure.
The diagnosis is established when there is a delayed commencement of eruption, distinctive morphology, histopathological findings that exclude lupus erythematosus, and a history of the eruption disappearing within a few days. For plaque-type polymorphous light eruption (PMLE), it is necessary to perform a biopsy and immunofluorescence investigations in order to exclude the possibility of lupus. Photo-testing involves the use of both UVB and UVA.
Test sites are regularly subjected to daily exposure of UVB and UVA radiation for a duration of 1 week to 10 days, with varying levels of UV dosage. Confirmation of the diagnosis is achieved when a PMLE-like eruption appears in the test locations of over 50% of patients. The eruption observed in the test site closely resembles the sort of Polymorphous Light Eruption (PMLE) observed in that specific patient.
Sunblocks, including high-strength UVAUVB sunscreens, may not always provide complete protection, but they should always be the initial choice. Administering systemic β-carotene at a dosage of 60 mg three times a day for a duration of 2 weeks before to exposure can potentially prevent eruptions. Similarly, using oral prednisone at a dosage of 20 mg per day, starting 2 days before exposure and continuing for 2 days during exposure, may also have a preventive effect. Administering 40 mg of intramuscular triamcinolone acetonide a few days before exposure will effectively suppress an eruption.
PMLE refers to a collection of diverse, unexplained, acquired, and recurring skin rashes that occur as a delayed response to exposure to UV radiation. Polymorphic light eruption (PMLE) is the prevailing form of photodermatitis, typically occurring in individuals during their third decade of life. Prevalence is higher among women compared to men, as well as among those with lighter skin. Actinic prurigo is a genetic condition found in American Indians in both North and South America.
Lesions manifest during the early spring and summer seasons, characterized by the presence of erythematous macules, papules, plaques, and vesicles. Nevertheless, in every case, the eruption consistently manifests as only one kind, most commonly papular or papulovesicular. PMLE often manifests shortly after exposure and persists for a duration of 7-10 days. Occasionally, towards the end of the summer, the eruptions cease to happen, indicating a process of solidification. The symptoms include pruritus (itching that may occur before the rash appears) and paresthesia (tingling sensation).
Abnormalities
The papular and papulovesicular forms are the most common. Plaques or urticarial plaques are far less frequent. The lesions have a color spectrum ranging from pink to red. The eruption often avoids locations that are regularly exposed (such as the face and neck) and is most commonly seen on the forearms, V area of the neck, arms, and chest. Lesions may also manifest on the face in the absence of prior sun exposure.
The diagnosis is established when there is a delayed commencement of eruption, distinctive morphology, histopathological findings that exclude lupus erythematosus, and a history of the eruption disappearing within a few days. For plaque-type polymorphous light eruption (PMLE), it is necessary to perform a biopsy and immunofluorescence investigations in order to exclude the possibility of lupus. Photo-testing involves the use of both UVB and UVA.
Test sites are regularly subjected to daily exposure of UVB and UVA radiation for a duration of 1 week to 10 days, with varying levels of UV dosage. Confirmation of the diagnosis is achieved when a PMLE-like eruption appears in the test locations of over 50% of patients. The eruption observed in the test site closely resembles the sort of Polymorphous Light Eruption (PMLE) observed in that specific patient.
Sunblocks, including high-strength UVAUVB sunscreens, may not always provide complete protection, but they should always be the initial choice. Administering systemic β-carotene at a dosage of 60 mg three times a day for a duration of 2 weeks before to exposure can potentially prevent eruptions. Similarly, using oral prednisone at a dosage of 20 mg per day, starting 2 days before exposure and continuing for 2 days during exposure, may also have a preventive effect. Administering 40 mg of intramuscular triamcinolone acetonide a few days before exposure will effectively suppress an eruption.
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Dermatology - Disseminated Intravascular Coagulation
Disseminated intravascular coagulation is a prevalent condition characterized by abnormal blood clotting that occurs throughout the blood arteries. This disorder is commonly linked to many clinical situations such as bacterial sepsis, obstetric difficulties, disseminated malignancy, or severe trauma.
The clinical manifestations of DIC can vary from mild and asymptomatic to severe and potentially fatal. The symptoms manifest gradually over a period of hours to days, characterized by fever, chills, tachycardia, and potentially indicators of shock. Hemorrhage can also occur from various cutaneous sites, such as surgical wounds, venipuncture, or catheter sites. Bleeding from the gums may also happen.
Infarction (purpura fulminans) or extensive ecchymoses arise with sharp, irregular (“geographic”) boundaries with deep purple to blue color and erythematous halo and may evolve to hemorrhagic bullae or blue to black gangrene. Frequently, there are several symmetrical lesions located on the outermost parts of the limbs, regions subjected to pressure, lips, ears, nose, or torso. Peripheral acrocyanosis can progress to gangrene in the hands, feet, and tip of the nose, leading to autoamputation.
The diagnosis is made based on clinical observations and verified through coagulation testing. Possible causes of significant cutaneous infarctions that need to be considered are necrosis resulting from the start of warfarin treatment, heparin necrosis, calciphylaxis, and atheroembolization.
Administer systemic antimicrobials to treat infections. To manage bleeding or thrombosis, administer heparin, pentoxifylline, and protein C concentrate, while also providing supportive care.
Disseminated intravascular coagulation is a prevalent condition characterized by abnormal blood clotting that occurs throughout the blood arteries. This disorder is commonly linked to many clinical situations such as bacterial sepsis, obstetric difficulties, disseminated malignancy, or severe trauma.
The clinical manifestations of DIC can vary from mild and asymptomatic to severe and potentially fatal. The symptoms manifest gradually over a period of hours to days, characterized by fever, chills, tachycardia, and potentially indicators of shock. Hemorrhage can also occur from various cutaneous sites, such as surgical wounds, venipuncture, or catheter sites. Bleeding from the gums may also happen.
Infarction (purpura fulminans) or extensive ecchymoses arise with sharp, irregular (“geographic”) boundaries with deep purple to blue color and erythematous halo and may evolve to hemorrhagic bullae or blue to black gangrene. Frequently, there are several symmetrical lesions located on the outermost parts of the limbs, regions subjected to pressure, lips, ears, nose, or torso. Peripheral acrocyanosis can progress to gangrene in the hands, feet, and tip of the nose, leading to autoamputation.
The diagnosis is made based on clinical observations and verified through coagulation testing. Possible causes of significant cutaneous infarctions that need to be considered are necrosis resulting from the start of warfarin treatment, heparin necrosis, calciphylaxis, and atheroembolization.
Administer systemic antimicrobials to treat infections. To manage bleeding or thrombosis, administer heparin, pentoxifylline, and protein C concentrate, while also providing supportive care.
