Table Of Contenta LANGE medical book
SYMPTOM TO
DIAGNOSIS
An Evidence-Based Guide
Second Edition
Scott D. C. Stern, MD, FACP
Professor of Medicine
Co-Director, Junior Clerkship in Medicine
Clinical Director of Clinical Pathophysiology and Therapeutics
University of Chicago
Pritzker School of Medicine
Chicago, Illinois
Adam S. Cifu, MD, FACP
Associate Professor of Medicine
Co-Director, Junior Clerkship in Medicine
University of Chicago
Pritzker School of Medicine
Chicago, Illinois
Diane Altkorn, MD, FACP
Associate Professor of Medicine
Director, Senior Student Clerkships in Medicine
University of Chicago
Pritzker School of Medicine
Chicago, Illinois
New York Chicago San Francisco Lisbon London Madrid Mexico City
Milan New Delhi San Juan Seoul Singapore Sydney Toronto
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ISBN: 978-0-07-178131-2
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In memory of Kim Michele Stern
Scott Stern
In memory of my father, Dr. Robert Cifu
Adam Cifu
In memory of my father, Robert Seidman
Diane Altkorn
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Contents
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
1. The Diagnostic Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
2. Screening & Health Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
3. Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
4. Acid-Base Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
5. AIDS/HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
6. Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100
7. Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114
8. Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130
9. Cough, Fever, and Respiratory Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149
10. Delirium and Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169
11. Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181
12. Diarrhea, Acute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199
13. Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .212
14. Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229
15. Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248
16. Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .266
17. Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .275
18. Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .287
19. Hypercalcemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .305
20. Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .314
21. Hyponatremia and Hypernatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .327
22. Jaundice and Abnormal Liver Enzymes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .347
23. Joint Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .365
24. Rashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .386
25. Renal Failure, Acute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .405
26. Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .420
27. Weight Loss, Involuntary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .442
28. Wheezing and Stridor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .467
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .485
Color Insert appears between pages 404 and 405
v
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Contributing Authors
John Luc Benoit, MD Sarah Stein, MD
Section of Infectious Diseases and Global Health Section of Dermatology
Assistant Professor of Medicine Associate Professor of Medicine
Director, Infectious Diseases Fellowship Program Rashes (Coauthored with Adam Cifu)
Director, Travel Clinic
AIDS/HIV Infection (Coauthored with Scott Stern)
vii
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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 rea-
soning 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 concludes with
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 4 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, laboratory and radiologic tests for that specific disease. Whenever possible, we have listed the sensitivities, specificities,
and likelihood ratios for these findings and test results. This section allows us to point out the findings that help to “rule in” or “rule out”
the various diseases. We often suggest a test of choice. It is this part of the book in particular that separates this text from many others. In
the final section, Treatment, we review the basics of therapy for the disease being considered. Recognizing that treatment evolves at a rapid
pace, we have chosen to limit our discussion to the fundamentals of therapy rather than details that would become quickly out of date.
The second edition differs from the previous edition in several ways. First, there are five new chapters—Hypertension, Diabetes, Rashes,
HIV/AIDS, and Screening and Health Maintenance—as well as 4 pages of full-color images of rashes. Second, there is more emphasis on
highlighting the pivotal points for each symptom that help to focus a broad differential diagnosis into one tailored to the individual patient.
Third, history and physical exam findings so highly specific that they point directly to a particular diagnosis are indicated with the following
“fingerprint” icon:
FP = fingerprint
Fourth, the diagnostic algorithms at the end of each chapter are more uniform. Finally, all chapters have been updated to reflect new
information on diagnostic testing.
For generations the approach to diagnosis has been learned through apprenticeship and intuition. Diseases have been described in detail,
but the approach to diagnosis has not been formalized. In Symptom to Diagnosis we feel we have succeeded in articulating this science and
art and, at the same time, made it interesting to read.
Scott D. C. Stern, MD
Adam S. Cifu, MD
Diane Altkorn, MD
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