Differential Diagnosis – “V”

FIRST TRIMESTER

• Implantation bleeding. Abortion.
• Threatened. Complete. Incomplete. Missed.
• Ectopic pregnancy. Neoplasia.
• Hydatidiform mole. Cervix.

THIRD TRIMESTER

• Placenta previa. Placental abruption. Premature labor.
• Choriocarcinoma.

Irritative (bubble baths, sand).

Poor perineal hygiene.

Foreign body.

Associated systemic illness (group A streptococci, chickenpox).

Infections.

• Escherichia coli with foreign body.
• Shigella organisms.
• Yersinia organisms.

Infections (consider sexual abuse): Chlamydia trachomatis. Neisseria gonorrhoeae. Trichomonas  vaginalis.

Tumor (rare).

MAJOR CAUSES OF VALVULAR HEART DISEASE IN ADULTS

• Aortic Stenosis
• Bicuspid aortic valve. Rheumatic fever.
• Degenerative stenosis.
• Aortic Regurgitation
• Bicuspid aortic valve. Aortic dissection.
• Endocarditis. Rheumatic fever. Aortic root dilation.
• Mitral Stenosis
• Rheumatic fever.
• Mitral Regurgitation

CHRONIC

• Mitral valve prolapse.
• Left ventricular dilation.
• Posterior wall myocardial infarction.
• Rheumatic fever.
• Endocarditis.

ACUTE

• Posterior wall or papillary muscle ischemia.
• Papillary muscle or chordal rupture.
• Endocarditis.
• Prosthetic valve dysfunction.
• Systolic anterior motion of mitral valve.

TRICUSPID REGURGITATION

• Functional (annular) dilation.
• Tricuspid valve prolapse.
• Endocarditis.
• Carcinoid heart disease.

LARGE VESSEL DISEASE

• Arteritis
• Giant cell arteritis.
• Takayasu’s arteritis.
• Arteritis associated with Reiter’s syndrome (reactive arthritis), ankylosing spondylitis.

MEDIUM AND SMALL VESSEL DISEASE

• Polyarteritis  Nodosa
• Primary (idiopathic).
• Associated with viruses (hepatitis B or C, CMV, HIV, herpes zoster).
• Associated with malignancy (hairy cell leukemia).
• Familial Mediterranean fever.
• Granulomatous  Vasculitis
• Granulomatosis with polyangiitis (Wegener’s granulomatosis).
• Lymphomatoid   granulomatosis.
• Behçet’s  Disease
• Kawasaki Disease (Mucocutaneous Lymph Node Syndrome)

PREDOMINANTLY SMALL VESSEL DISEASE

• Hypersensitivity Vasculitis (Leukocytoclastic Vasculitis) Henoch-Schönlein  purpura.
• Mixed cryoglobulinemia. Serum sickness.
• Vasculitis associated with connective tissue diseases (SLE, Sjögren’s  syndrome).
• Vasculitis associated with specific syndromes: Primary biliary cirrhosis, Lyme disease, Chronic active hepatitis, Drug-induced vasculitis. Churg-Strauss Syndrome Goodpasture’s Syndrome
• Erythema Nodosum
• Panniculitis
• Buerger’s     Disease     (Thrombophlebitis Obliterans)

EMBOLIC DISEASE

• Infectious or marantic endocarditis. Cardiac mural thrombus.
• Atrial myxoma.
• Cholesterol embolization syndrome.

NONINFLAMMATORY VESSEL WALL DISRUPTION

• Atherosclerosis.
• Arterial fibromuscular dysplasia.
• Drug effects (vasoconstrictors, anticoagulants).
• Radiation.
• Genetic disease (neurofibromatosis, EhlersDanlos syndrome).
• Amyloidosis.
• Intravascular malignant lymphoma.

DIFFUSE COAGULATION

• Disseminated intravascular coagulation.
• Thrombotic thrombocytopenic purpura.
• Hemolytic-uremic syndrome.
• Protein C and S deficiencies, factor V/Leiden mutation.
• Antiphospholipid  syndrome.

PERSISTENT VEGETATIVE STATE: COMMON CAUSES 

• Trauma (diffuse axonal injury).
• Cardiac arrest and hypoperfusion (laminar necrosis of cortical mantle and/or thalamic necrosis).
• Bihemispheric infarctions.
• Purulent meningitis or encephalitis (cortical injury).
• Carbon monoxide.
• Prolonged hypoglycemic coma.

• Pulmonary embolism.
• Emphysema.
• Irradiation.
• Pulmonary hypertension.
• AV  malformations.
• Pulmonary thrombosis.
• External compression of pulmonary artery (neoplasm, cysts, fibrosing mediastinitis).
• Vasculitis. Tuberculosis.
• Pulmonary thrombosis.
• Congenital (pulmonary artery hypoplasia, congenital heart disease with upper lobe diversion).
• Sequestered segment.
• Parasitic lung disease.
• Intraluminal obstruction from catheter fragments.

LEFT VENTRICULAR FAILURE

• Systemic  hypertension.
• Valvular heart disease (AS, AR, MR).
• Cardiomyopathy, myocarditis. Bacterial endocarditis.
• Myocardial infarction.
• Idiopathic hypertrophic subaortic stenosis.

RIGHT VENTRICULAR FAILURE

• Valvular heart disease (mitral stenosis).
• Pulmonary  hypertension.
• Bacterial endocarditis (right-sided).
• Right ventricular infarction.

BIVENTRICULAR FAILURE

• Left ventricular failure.
• Cardiomyopathy.
• Myocarditis
• Arrhythmias.
• Anemia.
• Thyrotoxicosis.
• Arteriovenous fistula.
• Paget’s disease.
• Beriberi.

• Warts.
• Seborrheic keratosis.
• Lichen simplex.
• Acanthosis  nigricans.
• Scabies (Norwegian, crusted).
• Verrucous  carcinoma.
• Nevus sebaceous.
• Deep fungal infection.

PERIPHERAL

• Otitis media.
• Acute labyrinthitis.
• Vestibular neuronitis.
• Benign positional vertigo.
• Meniere’s  disease.
• Ototoxic drugs: streptomycin, gentamicin.
• Lesions of the eighth nerve: acoustic neuroma, meningioma, mononeuropathy, metastatic carcinoma.
• Mastoiditis.

CNS OR SYSTEMIC

• Vertebrobasilar artery insufficiency.
• Posterior fossa tumor or other brain tumors.
• Infarction/hemorrhage of cerebral cortex, cerebellum, or brain stem.
• Basilar migraine.
• Metabolic: drugs, hypoxia, anemia, fever.
• Hypotension/severe hypertension.
• Multiple sclerosis.
• CNS infections: viral, bacterial.
• Temporal lobe epilepsy.
• Arnold–Chiari malformation, syringobulbia.
• Psychogenic: ventilation, hysteria.

MAJOR CAUSES OF CENTRAL VERTIGO

Demyelination.

• Acquired.
• Leukodystrophies.
• Multiple sclerosis.

Familial disorders.

• Friedreich ataxia.
• Spinocerebellar  ataxia.
• Familial episodic ataxia (type 1 and type 2).
• Olivopontocerebellar  atrophy.

Central nervous system infections.

• Lyme  neuroborreliosis.
• Meningitis.
• Tuberculosis.

Intrinsic brainstem lesion.

• Tumor.
• Arteriovenous malformation.
• Trauma.

Migraine.

• Basilar.
• Benign paroxysmal positional vertigo of childhood.

Toxins.

• Drugs, alcohol.
• Analgesics.
• Anticonvulsants.
• Antihypertensives.
• Hypnotics.
• Tranquilizers.

Metabolic and endocrine disorders.

• Hyperinsulinism.
• Impaired glucose tolerance.
• Diabetes mellitus.
• Hypertriglyceridemia.
• Hypothyroidism.

Systemic conditions.

• Paget disease.

Stroke/ischemia.

• Vertebrobasilar.
• Cerebellar.
• Posterior inferior cerebellar artery syndrome.
• Lateral medullary syndrome.
• Medial medullary infarct.
• Basilar artery syndrome.
• Anterior inferior cerebellar artery.

Other causes of posterior ischemia.

• Subclavian steal syndrome.
• Rotational vertebral artery occlusion syndrome.
• Vertebral artery dissection.
• Vertebral or basilar artery dolichoectasia.
• Neoplasm of the fourth ventricle.
• Chiari malformation.
• Superficial siderosis of the central nervous system.
• Vestibular epilepsy.

IMMUNOLOGICALLY MEDIATED DISEASES

• Bullous pemphigoid.
• Herpes  gestationis.
• Mucous membrane pemphigoid.
• Epidermolysis bullosa acquisita.
• Dermatitis herpetiformis.
• Pemphigus (vulgaris, foliaceus, paraneoplastic).

HYPERSENSITIVITY DISEASES

• Erythema multiforme minor.
• Erythema multiforme major (Stevens-Johnson syndrome).
• Toxic epidermal necrolysis.

METABOLIC DISEASES

• Porphyria cutanea tarda.
• Pseudoporphyria.
• Diabetic blisters.

INHERITED  GENETIC DISORDERS

Epidermolysis bullosa.

• Simplex.
• Junctional.
• Dystrophic.

INFECTIOUS DISEASES

• Impetigo.
• Staphylococcal scalded skin syndrome.
• Herpes simplex.
• Varicella.
• Herpes zoster.

• Acute angle-closure glaucoma.
• Corneal ulcer.
• Uveitis.
• Endophthalmitis.
• Factitious.
• Somatization syndrome.
• Trauma.

• Retinal artery occlusion.
• Optic neuritis.
• Retinal vein occlusion.
• Vitreous hemorrhage.
• Retinal detachment.
• Ischemic optic neuropathy.
• Factitious.
• Exudative macular degeneration.
• CVA.
• Ischemic optic neuropathy.
• Factitious.
• Somatization syndrome, anxiety reaction

• Decompression
• Arterial gas
• Bubbles under contact
• Displaced contact
• Antifog agent
• Contact lens adherence
• Transdermal scopolamine
• Hyperoxic
• Oxymetazoline optic
• Diving-induced migraine phenomena
• Eye disorders not related to diving

• Craniopharyngioma.
• Hereditary optic atrophy.
• Optic nerve glioma.
• Glioma of chiasm.
• Albinism.
• Optic nerve hypoplasia

• Thromboembolism.
• Vasculitis.
• Migraine (vasospasm).
• Anxiety reaction.
• CNS tumor.
• Temporal arteritis.
• Multiple sclerosis.

Acute posterior vitreous detachment associated either with a retinal tear or avulsion of a peripheral vessel.

Proliferative retinopathies.

• Diabetic.
• Following retinal vein occlusion.
• Sickle cell disease. Eales disease.
• Vasculitis.

Miscellaneous retinal disorders.

• Macroaneurysm.
• Telangiectasis
• Capillary hemangioma.

Systemic.

• Bleeding disorders.
• Terson  syndrome.

• Neoplasm: primary or metastatic (e.g., lung, thyroid, parathyroid, mediastinum).
• Neck surgery (parathyroid, thyroid, carotid endarterectomy, cervical spine).
• Idiopathic.
• Viral, bacterial, or fungal infection.
• Trauma (intubation, penetrating neck injury).
• Cardiac surgery.
• RA.
• Multiple sclerosis.
• Parkinsonism.
• Toxic neuropathy.
• CVA.
• CNS abnormalities: hydrocephalus, Arnold– Chiari malformation, meningomyelocele.

GI losses:

• Upper: bleeding, nasogastric suction, vomiting.
• Lower: bleeding, diarrhea, enteric or pancreatic fistula, tube drainage.

Renal losses:

• Salt and water: diuretics, osmotic diuresis, postobstructive diuresis, acute tubular necrosis (recovery phase), salt-losing nephropathy, adrenal insufficiency, renal tubular acidosis.

Water loss: diabetes insipidus.

Skin and respiratory losses:

• Sweat, burns, insensible losses.

Sequestration without external fluid loss:

• Intestinal obstruction, peritonitis, pancreatitis, rhabdomyolysis, internal bleeding

PRIMARY RENAL SODIUM RETENTION (INCREASED EFFECTIVE CIRCULATING VOLUME)

• Renal failure, nephritic syndrome, acute glomerulonephritis.
• Primary hyperaldosteronism.
• Cushing’s  syndrome.
• Liver disease.

SECONDARY RENAL SODIUM RETENTION (DECREASED EFFECTIVE CIRCULATING VOLUME)

• Heart failure.
• Liver disease.
• Nephrotic syndrome (minimal change disease).
• Pregnancy

GI disturbances:

• Obstruction: esophageal, pyloric, intestinal.
• Infections: viral or bacterial enteritis, viral hepatitis, food poisoning, gastroenteritis.
• Pancreatitis.
• Appendicitis.
• Biliary colic.
• Peritonitis.
• Perforated bowel.
• Diabetic  gastroparesis.

Other: gastritis, PUD, IBD, GI tract neoplasms.

Drugs: morphine, digitalis, cytotoxic agents, bromocriptine.

Severe pain: MI, renal colic.

Metabolic disorders: uremia, acidosis/alkalosis, hyperglycemia,  DKA, thyrotoxicosis.

Trauma: blows to the testicles, epigastrium. Vertigo.

Reye’s syndrome.

Increased intracranial pressure.

CNS disturbances: trauma, hemorrhage, infarction, neoplasm, infection, hypertensive encephalopathy,  migraine.

Radiation  sickness.

Nausea and vomiting of pregnancy, hyperemesis gravidarum.

Motion sickness.

Bulimia, anorexia nervosa.

Psychogenic: emotional disturbances, offensive sights or smells.

Severe coughing.

Pyelonephritis.

Boerhaave’s  syndrome.

Carbon monoxide poisoning.

CAUSES OF NEONATAL VOMITING

Anatomic Causes

Esophagus, trachea, great vessels:

• Stricture.
• Web
• Tracheoesophageal fistula.
• Laryngeal cleft.
• Double aortic arch.

Stomach and duodenum:

• Pyloric stenosis.
• Duodenal atresia (usually noted on the first day of life)

Small and large intestine:

• Volvulus secondary to malrotation.
• Incarcerated hernia.
• Hirschsprung disease (secondary to obstipation).
• Necrotizing enterocolitis.

Genitourinary:

• Testicular torsion.

Nonanatomic Causes

Infection:

• Septicemia.
• Meningitis.
• Urinary tract infection.
• Gastroenteritis.
• Otitis media

Increased intracranial pressure:

• Cerebral edema.
• Subdural hematoma.
• Hydrocephalus.
• Brain tumor.

Congenital adrenal hyperplasia (salt-losing variety).

Inborn errors of metabolism.

Renal disease

RED LESION

Infection/Infestation

Fungal infection:

• Candida.
• Tinea cruris.
• Intertrigo.
• Pityriasis versicolor.

Sarcoptes  scabiei.

Erythrasma: Corynebacterium minutissimum.

Granuloma inguinale: Calymmatobacterium granulomatis.

Folliculitis: Staphylococcus aureus.

Hidradenitis suppurativa.

Behçet’s  syndrome.

Inflammation

Reactive vulvitis.

Chemical irritation:

• Detergent.
• Dyes.
• Perfume.
• Spermicide.
• Lubricants.
• Hygiene sprays.
• Podophyllum.
• Topical 5-FU. Saliva.
• Gentian violet.
• Semen.

Mechanical trauma: scratching.

Vestibular  adenitis.

Essential vulvodynia. Psoriasis.

Seborrheic dermatitis.

Neoplasm

Vulvar intraepithelial neoplasia (VIN):

• Mild dysplasia.
• Moderate dysplasia.
• Severe dysplasia.
• Carcinoma-in-situ.

Vulvar dystrophy.

Bowen’s disease.

Invasive cancer:

• Squamous cell carcinoma.
• Malignant melanoma.
• Sarcoma.
• Basal cell carcinoma.
• Adenocarcinoma.

Paget’s disease.

Undifferentiated.

WHITE LESION

Vulvar dystrophy:

• Lichen sclerosus.
• Vulvar dystrophy.
• Vulvar hyperplasia.
• Mixed dystrophy.

VIN.

Vitiligo.

Partial albinism.

Intertrigo.

Radiation treatment.

DARK LESION

Lentigo.

Nevi (mole).

Neoplasm (see “Neoplasm, Vulvar,” below).

Reactive  hyperpigmentation.

Seborrheic keratosis.

Pubic lice.

ULCERATIVE LESION

Infection

• Herpes simplex.
• Vaccinia.
• Treponema pallidum.
• Granuloma inguinale.
• Pyoderma.
• Tuberculosis.

Noninfectious

• Behçet’s disease.
• Crohn’s disease.
• Pemphigus.
• Pemphigoid.
• Hidradenitis suppurativa (see “Neoplasm, Vulvar,” below).

Neoplasm

• Basal cell
• Squamous cell

Vulvar tumor <1 cm:

• Condyloma Molluscum contagiosum.
• Epidermal inclusion.
• Vestibular cyst.
• Mesonephric duct.
• VIN.
• Hemangioma.
• Hidradenoma.
• Neurofibroma.
• Syringoma.
• Accessory breast tissue.
• Acrochordon.
• Endometriosis.
• Fox-Fordyce disease.
• Pilonidal sinus.

Vulvar tumor >1 cm:

• Bartholin cyst or abscess.
• Lymphogranuloma venereum.
• Fibroma.
• Lipoma.
• Verrucous carcinoma.
• Squamous cell carcinoma.
• Hernia.
• Edema.
• Hematoma.
• Acrochordon.
• Epidermal cysts.
• Neurofibromatosis.
• Accessory breast tissue.