Copyright © 2015 by McGraw-Hill Education All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-180345-8 MHID: 0-07-180345-9 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-180344-1, MHID: 0-07-180344-0 eBook conversion by codeMantra Version 1.0 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs To contact a representative, please visit the Contact Us page at www.mhprofessional.com Notice Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the 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may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” MCGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill Education and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill Education has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise In memory of Kim Michele Stern Scott Stern For Sarah, Ben, and Amelia Adam Cifu In memory of my father, Robert Seidman Diane Altkorn Contents Contributing Authors Preface Acknowledgments Diagnostic Process Screening and Health Maintenance Abdominal Pain Acid-Base Abnormalities AIDS/HIV Infection Anemia Back Pain Bleeding Disorders Chest Pain 10 Cough, Fever, and Respiratory Infections 11 Delirium and Dementia 12 Diabetes 13 Diarrhea, Acute 14 Dizziness 15 Dyspnea 16 Dysuria 17 Edema 18 Fatigue 19 GI Bleeding 20 Headache 21 Hematuria 22 Hypercalcemia 23 Hypertension 24 Hyponatremia and Hypernatremia 25 Hypotension 26 Jaundice and Abnormal Liver Enzymes 27 Joint Pain 28 Kidney Injury, Acute 29 Rash 30 Sore Throat 31 Syncope 32 Weight Loss, Unintentional 33 Wheezing and Stridor Index Contributing Authors Jean-Luc Benoit, MD Associate Professor of Medicine Section of Infectious Diseases and Global Health University of Chicago Chicago, Illinois AIDS/HIV Infection Philip Hoffman, MD Professor of Medicine Section of Hematology-Oncology University of Chicago Chicago, Illinois Bleeding Disorders (Coauthored with Diane Altkorn) Matthew Kalscheur, MD Cardiovascular Medicine Fellow University of Wisconsin Hospital and Clinics Madison, Wisconsin Hypotension (Coauthored with Scott Stern) Wei Wei Lee, MD Assistant Professor of Medicine Section of General Medicine University of Chicago Chicago, Illinois Sore Throat (Coauthored with Adam Cifu) Amber Pincavage, MD Assistant Professor of Medicine Section of General Medicine University of Chicago Chicago, Illinois Dysuria (Coauthored with Adam Cifu) Elizabeth Schulwolf, MD Assistant Professor of Medicine Division of Hospital Medicine Loyola University Medical Center Maywood, Illinois Screening and Health Maintenance (Coauthored with Diane Altkorn) Sachin Shah, MD Assistant Professor of Medicine Section of General Medicine University of Chicago Chicago, Illinois Hematuria (Coauthored with Diane Altkorn) Sarah Stein, MD Associate Professor of Medicine Section of Dermatology University of Chicago Chicago, Illinois Rash (Coauthored with Adam Cifu) Preface Our goal in creating Symptom to Diagnosis was to develop an interesting, practical, and informative approach to teaching the diagnostic process in internal medicine Interesting, because real patient cases are integrated within each chapter, complementing what can otherwise be dry and soporific Informative, because Symptom to Diagnosis articulates the most difficult process in becoming a physician: making an accurate diagnosis Many other textbooks describe diseases, but fail to characterize the process that leads from patient presentation to diagnosis Although students can, and often do, learn this process through intuition and experience without direct instruction, we believe that diagnostic reasoning is a difficult task that can be deciphered and made easier for students Furthermore, in many books the description of the disease is oversimplified, and the available evidence on the predictive value of symptoms, signs, and diagnostic test results is not included Teaching based on the classic presentation often fails to help less experienced physicians recognize the common, but atypical presentation This oversight, combined with a lack of knowledge of test characteristics, often leads to prematurely dismissing diagnoses Symptom to Diagnosis aims to help students and residents learn internal medicine and focuses on the challenging task of diagnosis Using the framework and terminology presented in Chapter 1, each chapter addresses one common complaint, such as chest pain The chapter begins with a case and an explanation of a way to frame, or organize, the differential diagnosis As the case progresses, clinical reasoning is clearly articulated The differential diagnosis for that particular case is summarized in tables that delineate the clinical clues and important tests for the leading diagnostic hypothesis and important alternative diagnostic hypotheses As the chapter progresses, the pertinent diseases are reviewed Just as in real life, the case unfolds in a stepwise fashion as tests are performed and diagnoses are confirmed or refuted Readers are continually engaged by a series of questions that direct the evaluation Each chapter contains several cases and includes a diagnostic algorithm Symptom to Diagnosis can be used in three ways First, it is designed to be read in its entirety to guide the reader through a third-year medicine clerkship We used the Core Medicine Clerkship Curriculum Guide of the Society of General Internal Medicine/Clerkship Directors in Internal Medicine to select the symptoms and diseases we included, and we are confident that the text does an excellent job teaching the basics of internal medicine Second, it is perfect for learning about a particular problem by studying an individual chapter Focusing on one chapter will provide the reader with a comprehensive approach to the problem being addressed: a framework for the differential diagnosis, an opportunity to work through several interesting cases, and a review of pertinent diseases Third, Symptom to Diagnosis is well suited to reviewing specific diseases through the use of the index to identify information on a particular disorder of immediate interest Our approach to the discussion of a particular disease is different than most other texts Not only is the information bulleted to make it concise and readable, but the discussion of each disease is divided into sections The Textbook Presentation, which serves as a concise statement of the common, or classic, presentation of that particular disease, is the first part The next section, Disease Highlights, reviews the most pertinent epidemiologic and pathophysiologic information The third part, Evidence-Based Diagnosis, reviews the accuracy of the history, physical exam, and laboratory and ... complementing what can otherwise be dry and soporific Informative, because Symptom to Diagnosis articulates the most difficult process in becoming a physician: making an accurate diagnosis Many other textbooks... leads to prematurely dismissing diagnoses Symptom to Diagnosis aims to help students and residents learn internal medicine and focuses on the challenging task of diagnosis Using the framework and... educator Olaf Andersen nurtured my interest in science and guided my entry into medicine Carol Bates showed me what it means to be a specialist in general medicine and a clinician educator My