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Diagnostic Dilemmas and D/Dx

1. fever and a rash in a sick person (lethal), often associated with multiple organ failure. (see also Evaluating the Febrile Patient with a Rash - August 15, 2000 - American Family Physician)
   • Kawasaki's
   • Leptospirosis
   • Smallpox
   • meningococcemia
   • Rheumatic fever
   • Rocky Mountain Spotted Fever (RMSF)
   • scarlet fever (staph and strep)
   • severe erythema multiforme
   • staph, strep sepsis
   • toxic shock syndromes (desquamation)
   • typhus
   • vasculitides
   • adult parvovirus
2. fever with bilateral conjunctivities and +/-purulent discharge
   • Kawasaki's (if child) (some say nonexudative d/c): mucosal erythema oropharynx, edema or erythema hands and feet
   • influenza (discharge not purulent), should have a dry cough, often GI complaint
3. "Viral Syndrome" (influenza): fever and myalgias but no cough and no rash. See also fever and a rash in a sick person
   • sepsis, severe strep
   • acute HIV (esp. with mucocutaneous ulceration)
   • mononucleosis
   • SBE
   • Ehrlichiosis: leukpenia, thrombocytopenia
   • Listeriosis
   • primary CMV, toxoplasmosis
   • drug reaction (malignant hyperthermia)
   • Lyme  (if coexist with babesiosis, Lyme by itself should not be so acutely ill, also should have a rash)
   • viral hepatitis
   • Primary HSV
   • foreign travel: malaria, Brucellosis
4. "Flu" with a widened mediastinum and impending death: Anthrax with necrotizing mediastinitus. Phone home and order the Cipro.
5. afebrile 3 mo old infant who is “flat” (generalized weakness)
   • botulism
   • d/dx: sepsis, myasthenia gravis (normal DTRs), Gulliaine-Barre (rare, incr CSF protein), polio (CSF WBC), dehydration, electrolytes, metabolic disease, Reyes, CVA, toxins.
6. Any weird complaint in an elderly person: do an ESR
   • above the neck: Temporal Arteritis (ex: facial numbness and occipital headache)
   • below the neck: Polymyalgia Rheumatica
7. assymetric hearing loss -> acoustic neuroma
8. appendicitis: cholecystitis, Crohn's, DKA, ectopic preg, GE, inguinal hernia, obstruction, Meckel's diverticulum, mesenteric adenitis, nephrolithiasis, ovarian torsion, PID, perforated CA colon, pneumonia, pyelo, sigmoid diverticiculum, testicular torsion tubo-ovaran abscess, acute porphyria
9. asthma not responding to therapy
   • vocal cord dysfunction: 27 yo nurse with sudden “attacks”, wheezing at larynx, able to speak, better with singing, abrupt recovery, normal methacholine and spirometry
10. atypical sciatica: piriformis syndrome
11. child with progressive weakness
    • tick paralysis: alert; afebrile; ataxia, absent DTRs, esp. in long-haired blond girl -- often mis-dx as Guillain-Barre
    • cincina poisoning or other fish neurotoxin
    • botulism
    • Guillain-Barre (esp. if history of Campylobacter jejuni infection)
    • myasthenia gravis
    • polio
12. Chronic Cough
13. chronic debilitation in an elderly person: late generalized tuberculosis
14. confusion + fever: infection, heat stroke, neuroleptic malignant syndrome, pheochromocytoma (less likely), hyperthyroid storm, CNS injury, drug ingestion, cholinergic poisoning.
15. confusion + hyper-irritability + myoclonus: serotonin syndrome, drug OD (cocaine), malignant hyperthermia, malignant neuroleptic syndrome, other toxin, poisoning
16. conjunctival (palpebral) polyp or soft granuloma with preauricular adenopathy: Parinaud’s Oculoglandular Syndrome
17. diarrhea, dyspnea, cough: Legionnaire's Disease
18. Facial numbness: MS, trauma incl dental, neoplasms in nasopharynx, sinusitis, syphilis, sarcoidosis and very weird local pressure items (carotid aneur, etc).
19. Flushing
    • with periorbital edema and heart murmur: carcinoid
    • unexplained: rx with guanfacine hcl or beta blocker
    • sexual arousal: mastocytosis
20. History of trauma due to an MVA but no insurance forms: suspect assault, especially domestic.
21. impotence, fatigue, joint pains: hemochromatosis
22. infant born to a sick febrile mother: Listeriosis
23. leukocytosis and hyperglycemia in a sick child: iron poisoning. lethargy, hypotension, tachycardia but low to no fever .. Iron tabs seen on x-ray.
24. Palpitations and new AV block: Lyme carditis
25. Parkinsonian features or movement disorder in young person: Wilson’s Disease
26. pleuritic pain, low grade fever
    • pulmonary embolus
    • Dressler’s post-mi pericarditis: EKG chgs, incr. ESR, better leaning forward, sitting
    • pnemonia: CXR chgs, sputum
    • pleurisy
27. scrotal pain & swelling & pp protoplasm -> Fournier’s Gangrene (necrotizing fasciitis of perineum)
28. sensory loss in the hands and spastic lower extremities in pt > 50 yo
    • cervical spondylosis with myelopathy
    • check B12
29. "Shingles" without a rash: Lyme radiculoneurpathy
30. sub-acute confusion in a young person
    • SSPE
    • slow-viral disease
    • heavy metal poisoning or other environmental toxin
31. Swelling and pain around any joint, even in the absence of erythema or increased temperature - consider crystalline deposition (gout, pseudogout), or acute Lyme monarticular arthritis.
32. swelling over the submandibular or sublingular area in children with fever: parotitis vs. Ludwig's Angina. LA kids sicker, can't open mouth, respiratory distress (emergency).
33. upgoing toes and absent knee jerks: Friedrich’s Ataxia
34. See unresponsive migraine
35. Child < 1 year with persistent pharyngitis and malaise: retropharyngeal abscess