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3. A cardiovascular examination including the heart for murmur or arrhythmia and carotid
arterial auscultation should be completed.
4. An otoscopic examination to assess infection and nystagmus examination including gaze,
Dix-Hallpike’s maneuvers, and head shaking are important.
5. An observation of gait to assess cerebellar function is also a part of the examination.
C. Testing. It is obvious that there is no laboratory test or imaging study directly related to
dizziness. Instead, these types of studies are dictated by the etiology that the clinician feels
is most likely. They are more to confirm a diagnosis than to actually make it.
1. Tests might include complete blood count, electrolytes, appropriate drug levels, and
thyroid levels.
2. Imaging studies such as magnetic resonance imaging might be indicated if the concern
of tumor is high.
3. A hearing test as well as maneuvers carried out in a tilt-chair to test labyrinth function
may be of value.
D. Genetics. There does not appear to be any genetic predisposition to dizziness.
IV. DIAGNOSIS
A. Differential Diagnosis.
1. The differential diagnosis of dizziness includes all of those conditions mentioned in the
preceding text that cause true dizziness (Table 2.2.1). It also includes many other
conditions that cause patients to feel abnormal in some vague way, causing them
to complain of dizziness. Psychologic conditions such as anxiety, depression, panic
disorder, or somatization may all cause a patient to complain of dizziness. Cardiac
arrhythmias, ischemic or valvular heart disease, vasovagal anemia, or postural hypo-
tension are some of the conditions leading to cerebral hypoperfusion, and therefore,
presyncope.
TABLE 2.2.1 Common Causes of Dizziness
Peripheral vestibular
a
Central vestibular
b
Psychiatric
c
Nonvestibular,
nonpsychiatric
d
Benign positional vertigo
Cerebrovascular
disease
e
Hyperventilation Presyncope
Labyrinthitis Tumors
f
– Disequilibrium
Meniere’s disease Cerebellar atrophy – Medications
Other
g
Migraine – Metabolic disturbances
Multiple sclerosis – Infection
Epilepsy – Trauma
– – Unknown causes
h
a
Encompasses 44% of patients.
b
Accounts for 11% of dizziness cases.
c
Causes make up 16% of the diagnosis.
d
Accounts for 37% of the diagnosis.
e
Stroke or transient ischemic attack and dehydration comprise the largest part of this group.
f
Usually acoustic neuroma.
g
Includes drug-induced, ototoxicity, and nonspecific vestibulopathy.
h
A significant part of this subset and a significant part of all cases of dizziness.
8
Taylor’s DifferenTial Diagnosis Manual
2. Degenerative changes in the elderly may affect the vestibular apparatus, vision, or pro-
prioception, all of which may be interpreted as dizziness. Finally, peripheral neuropathy
or cerebellar disease may also be confused with dizziness.
B. Clinical Manifestations.
The clinical manifestations of dizziness are as varied as those entities included in both the
etiologic and the differential diagnosis sections. The fact that dizziness is more often a symp-
tom of some other condition than a separate diagnosis leads to a variety of manifestations
that the clinicians must decipher.
REFERENCES
1. M. Bajorek. Night sweats. In: Taylor R, ed. The 10-minute diagnosis manual. Philadelphia, PA:
Lippincott Williams & Wilkins, 200:31–33.
2. Kroenke K, Hoffman R, Einstadter D. How common are various causes of dizziness? A critical review.
South Med J 2000;93(2):160–168, Table 2, P7.
3. Sloane PD. Dizziness in primary care: results from the National Ambulatory Medical Care Survey.
J Fam Pract 1989;29:33–38.
2.3
Edema
Jennifer J. Buescher
I. BACKGROUND. Edema is caused by an abnormality in fluid exchange affecting capillary
hemodynamic forces, sodium and water exchange in the kidney, or both (1). Edema is a com-
mon symptom in many different medical conditions.
II. PATHOPHYSIOLOGY
A. Etiology.
The kidneys maintain a balance between extracellular fluid volume and effective
arterial blood volume by adjusting water and sodium excretion (2). Maintaining a plasma
volume sufficient for oxygen delivery to the tissues is the most important factor at play. Fluid
will move to the extracellular space when the capillary hydraulic pressure is elevated, plasma
oncotic pressure decreases, interstitial oncotic pressure increases, or capillary permeability
increases. The increase in extracellular (interstitial) fluid causes edema (1).
B. Epidemiology. Edema is a common problem in clinical practice in both acute and chronic
conditions.
III. EVALUATION
A. History.
Edema is seen in many diverse clinical conditions and therefore a complete
history is necessary for an accurate diagnosis. A thorough medication history is also
important as many common prescription medications can cause or worsen edema. The
history should include the onset of symptoms, associated pain, dietary intake, preg-
nancy, trauma to the affected area, recent travel, and work history. Acute onset of edema
can be indicative of acute lymphatic or venous obstruction, which may require urgent
action. Chronic edema is more likely caused by chronic cardiac, liver, or kidney disease (2).
Myxedema caused by untreated hypothyroidism can also be a cause of generalized
chronic edema.
B. Review of Symptoms. The review of systems must be thorough in the evaluation of
edema to differentiate the multiple medical causes of edema. Special attention should be
paid to the cardiac, pulmonary, joint, extremity, and gastrointestinal (GI) symptoms.
C. Physical Examination. The physical examination should focus on the location and
severity of swelling, skin breakdown, and signs that would help differentiate the many
Chapter 2 • Undifferentiated Problems
9
causes of edema. Unilateral or nondependent edema should be evaluated urgently for
deep venous thrombosis or lymphatic obstruction from a tumor. Bilateral or dependent
edema is most commonly associated with congestive heart failure and abdominal edema
is more indicative of hepatic abnormalities. Generalized edema of both the upper and
lower extremities and trunk should raise a concern for nephrotic syndrome or other renal
abnormalities (1). Dependent edema is common in normal pregnancy, but upper extremity
or severe edema in pregnancy can be a sign of preeclampsia and should be evaluated more
thoroughly.
D. Testing. Testing should be directed by the history, review of systems, and examination.
Evaluation may include a metabolic panel, liver enzymes, thyroid stimulating hormone,
echocardiogram, abdominal ultrasound, vascular ultrasound of the extremity, or other diag-
nostic tests.
IV. DIAGNOSIS
A differential diagnosis for edema is listed in Table 2.3.1. A complete history and physical
examination paired with focused laboratory and radiologic evaluation is necessary for the accu-
rate diagnosis of edema.
REFERENCES
1. O’Brien JG, Chennubhotle SA, Chennubhotla RV. Treatment of edema. Am Fam Physician
2005;71(11):2111–2117.
2. Braunwald E, Loscalzo J. Edema. In: Anthony EB, Fauci S, eds. Harrison’s principles of internal medi-
cine, Chapter 36, 17th ed. New York, NY: McGraw-Hill, 2008:290–295.
TABLE 2.3.1 Differential Diagnosis of Edema
Lymphedema
Postsurgical
Mass effect from tumor
Posttraumatic changes
Deep venous thrombosis
Myxedema: hypothyroidism
Acute trauma or fracture
Congestive heart failure
Cirrhosis
Nephrotic syndrome
Iatrogenic edema (excessive standing, tight clothing, etc.)
Medication-induced
Nonsteroidal anti-inflammatory drugs
Calcium channel antagonists
Estrogens
Vasodilators
Corticosteroids
Information adapted from O’Brien J. G., Chennubhotle, S. A., & Chennubhotla, R. V. (2005).
Treatment of Edema. American Family Physician, 2005;71 (11): 2111–2117; Braunwald E, Loscalzo
J. In: Anthony EB, Fauci S, eds. Harrison’s principles of internal medicine, Chapter 36, 17th ed. New
York, NY: McGraw-Hill, 2008.
10
Taylor’s DifferenTial Diagnosis Manual
2.4
Falls
Kenneth D. Peters
I. BACKGROUND. Falls are most common at age extremes. In children older than 1 year of
age, injuries are the number one cause of death. Falls account for 25% of these. Bike injuries
account for 68% of injuries in children from 5 to 14 years of age (1). In patients older than
65 years of age, the incidence of falls is 30%; in those older than 80 years of age, it is >50%.
Accidents are the fifth leading cause of death in patients 65 years of age and older, and falls
account for two-thirds of these deaths. Of elderly patients hospitalized for falls, only 50% are
alive 1 year later (2).
II. PATHOPHYSIOLOGY. Factors that contribute to falls need to be identified and evaluated for
preventative measures to be taken. Children fall from heights; elderly fall from level surfaces.
A. Children and Adolescents. Fall from heights over 3 feet and falls of infants younger than
1 year of age result in increased risk of skull fracture and intracranial bleeding. Emergent
evaluation is needed in cases of loss of consciousness, behavioral changes, seizures, or ongo-
ing vomiting.
B. Falls in the Elderly. One half of the falls are secondary to accidents, including fac-
tors affecting stability. The other half of the falls are secondary to medical disorders (see
Table 2.4.1). If syncope occurred with a fall, it must be determined whether the cause is
cardiac or noncardiac (see Table 2.4.2) (Chapter 2.12). Cardiac mortality in falls related
to syncope at 1 year is 20% to 30%, whereas noncardiac mortality is <5% (3). There is a
strong association between falls and nursing home placement in the elderly; furthermore,
specific individualized interventions help prevent falls (4). The risk of hip fracture in the frail
elderly can be reduced with the use of an anatomically designed external hip protector (5).
III. EVALUATION
A. History.
1. History of the Fall. An interview of a witness to the fall is essential. This may identify
any seizure activity, loss of consciousness, and method of fall. Ask what the patient was
doing prior to the fall, including occurrence with positional changes or after voiding,
eating, or constipation. Are there associated palpitations implying arrhythmia? Did the
patient have a fall or syncope during exercise, which may indicate a cardiac cause? Is there
any confusion that is new or changed from the past that suggests central nervous system
trauma or seizure? Was urine or bowel incontinence present? Questions concerning
home and risk factors should be raised (Table 2.4.1).
2. Past History. Explore coexisting illness that may have contributed to the fall
(Table 2.4.1). A family history of sudden death can imply arrhythmias. Furthermore,
inquire about any family history of prior falls.
B. Physical Examination. This should include:
1. Assessment of vital signs, including heart rate and rhythm, orthostatic blood pressure
changes, temperature, and respiratory rate.
2. A general body survey for any evidence of trauma.
3. Examination of the eye (fundoscopic, visual acuity, and fields), mouth (tongue lac-
erations), neck (bruits), lung (congestive heart failure or infection), and cardiovascular
(murmurs and rhythm).
4. A neurologic examination that includes mental status, evaluation of balance, gait, mobil-
ity, and tests for peripheral neuropathy.
5. The “get up and go test” (rise from a chair, walk 10 feet, return, and sit down), which
is a simple rapid way of assessing general condition and musculoskeletal and neurologic
status.
Chapter 2 • Undifferentiated Problems
11
C. Testing
1. Clinical Laboratory Tests. Most blood tests are low yield and should be done to con-
firm clinical suspicion. An electrocardiogram is useful in the elderly to rule out arrhyth-
mia, atrioventricular block, prolonged QT syndrome, or ischemia. A diagnosis of the
cause of the fall can be obtained in 50% to 60% of cases based on history, physical, and
electrocardiographic study (7).
2. Diagnostic Imaging. Skull x-ray (fracture) and computed tomography studies to detect
intracranial bleeding are recommended in all infants younger than 1 year of age or if the
fall was from >3 feet. Also consider imaging with any loss of consciousness, evidence of
head trauma, behavioral changes, seizure disorder, ongoing vomiting, or focal neurologic
deficits.
3. Other testing to consider includes echocardiogram (valvular heart disease), electroen-
cephalogram (seizure), carotid ultrasound (bruits), carotid sinus massage (if suggested
history), and tilt table testing (if a vasovagal cause of fall is considered). Ambulatory
cardiac monitor is considered for sudden infrequent falls.
IV. DIAGNOSIS
A fall by an elderly individual frequently requires a home visit to evaluate factors contributing
to falls and to correct unsafe conditions (Table 2.4.1). Symptoms of cardiac disease can occur
with exertion or straining. Cardiac arrhythmias tend to be sudden without warning, although
TABLE 2.4.1 Factors Affecting Falls
Factors affecting stability Medical problems contributing to falls
Decreased muscle tone/strength Arthritis
Changes in gait Previous stroke
Changes in postural control Hip fracture
Decreased depth perception Dementia
Decreased hearing Osteoporosis
Decreased proprioception Parkinsonism
Decreased vision Foot disorders
Slower reflexes Peripheral neuropathies
Hazardous living arrangements (e.g., poor lighting,
slick floors, loose rugs, stairways, unstable furniture)
Hyperthyroidism
Alcoholism
Medications
Hypertension
Hypotension
Myocardial infarction
Arrhythmias
Congestive heart failure
Acute stroke
Internal bleeding
Infections
Valvular heart disease
Seizures
12
Taylor’s DifferenTial Diagnosis Manual
once in a while patients can complain of palpitations. Noncardiac causes include vasovagal
reaction where the patient generally complains of dizziness or lightheadedness prior to a fall,
often with changes in position or when upright. These can be associated with sweating and
nausea. Orthostatic noncardiac causes have gradual onset and resolution. These are most often
associated with medications, including antihypertensives, sedatives, anxiolytics, antidepressants,
hypoglycemics, psychotropics, histamine-2 blockers, alcohol, over-the-counter cold medicines,
and medications with extended half-lives. Neurologic noncardiac events can usually be diag-
nosed by history and physical examination. A psychiatric cause for falls in less likely, but one
should be suspicious in cases of frequent symptoms with no injury.
For the differential diagnosis, refer to Tables 2.4.1 and 2.4.2.
REFERENCES
1. Gruskin KD, Schutzman SA. Head trauma in children younger than 2 years: are there predictors for
complications? Arch Pediatr Adolesc Med 1999;153:15–20.
2. Steinweg KK. The changing approach to falls in the elderly. Am Fam Physician 1997;56:1815–1824.
3. Wiley TM. A diagnostic approach to syncope. Resid Staff Physician 1998;44:2947.
4. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. New
Engl J Med 1997;337(18):1279–1284.
5. Kannus P, Parkkari J, Niemi S. Prevention of hip fracture is elderly people with use of a hip protector.
New Engl J Med 2000:343(21):1506–1513.
6. Albert S, David R, Alison M. Comprehensive geriatric assessment. In: William H, Edwin B, John B,
et al. eds. Principals of geriatrics, 3rd ed. New York, NY: McGraw-Hill, 1994: Chapter 17:206.
7. Hupert N, Kapoor WN. Syncope: a systemic approach for the cause. Patient Care 1997; 31:136–147.
TABLE 2.4.2 Causes of Syncope
Cardiac Noncardiac
Obstructive Vasovagal
Valvular disease Pain
Hypertrophic cardiomyopathy Voiding
Pulmonary hypertension Increased stress
Pulmonary emboli Cough
Myxomas Simple faint
Arrhythmia Carotid sinus disease
Sick sinus syndrome Orthostatic
Atrial fibrillation Medication
Arrhythmias Volume depletion
Diabetes
Parkinsonism
Neurologic
Stroke
Seizure
Migraine
Chapter 2 • Undifferentiated Problems
13
2.5
Fatigue
Amy K. Jespersen
I. BACKGROUND
A. General Considerations.
Fatigue is a very common complaint in the primary care office.
It may be the primary reason a patient seeks care or a secondary complaint. We are all both-
ered by fatigue at some point in time. However, for millions of patients each year, it becomes
bothersome enough to seek medical attention. True fatigue needs to be distinguished from
weakness and from excessive somnolence secondary to sleep disturbances. Fatigue lasting less
than a month is considered acute. If symptoms last more than a month, fatigue is considered
prolonged.
B. Definitions.
1. Chronic fatigue is diagnosed when symptoms last >6 months. The Center for Disease
Control and Prevention has defined chronic fatigue syndrome (CFS) as profound fatigue
of 6 months’ duration that presents with four of the following eight symptoms:
a. Impairment in the short-term memory or concentration
b. Sore throat
c. Tender lymphadenopathy
d. Myalgias
e. Pain in multiple joints
f. Headaches of a new type, pattern, or severity
g. Unrefreshing sleep
h. Postexertional malaise lasting >24 hours (1)
2. Idiopathic chronic fatigue is diagnosed if a patient has been fatigued for >6 months but
does not meet the criteria for CFS.
II. PATHOPHYSIOLOGY
A. Etiology.
Some of the common causes of CFS are listed in Table 2.5.1. Fatigue may be
due to medical disorders, psychiatric disease, or lifestyle factors. In some cases, a cause is
never determined. Fatigue that persists for several months or years is more likely to have
psychiatric etiology, whereas a shorter duration of fatigue is more likely to have a medical
explanation (2). If a medical cause of fatigue is present, it is usually identifiable on the initial
history, physical, and laboratory testing (3, 4).
B. Epidemiology. The true incidence of profound fatigue is unknown. It has been estimated
that over 7 million office visits per year are for complaints of fatigue (3). The true gender
predilection is also unknown; however, women present to the physician’s office twice as often
as men. Patients younger than 45 years of age are more likely to present for fatigue than
patients older than 45 years of age (2).
III. EVALUATION
A. History.
1. A detailed history and review of systems should be performed. The onset, duration,
and degree of fatigue should be explored, along with any possible precipitating events.
Specific attention should be given to sleep patterns, daytime somnolence, or sleep apnea
symptoms.
2. The patient’s exercise habits, caffeine intake, and drug or alcohol use should be explored,
and medications should be reviewed.
3. A psychiatric history to evaluate symptoms of depression or anxiety should be obtained.
Lifestyle issues such as stress at home or in the work place, childcare responsibilities, shift
work, or changed work schedules should be addressed.
14
Taylor’s DifferenTial Diagnosis Manual
B. Physical Examination. A thorough physical examination should be performed. Vital
signs should be carefully noted. Attention should be given to the presence of pallor, muscle
weakness, goiter, lymphadenopathy, and body habitus. A psychiatric evaluation for signs of
depression, anxiety, or other mental illness should be performed. In older adults, a mental
status exam to evaluate cognitive function may be appropriate.
C. Testing.
1. Initial laboratory testing should be limited to:
a. Complete blood count
b. Comprehensive metabolic profile
c. Thyroid-stimulating hormone
d. Erythrocyte sedimentation rate
2. Other tests may be indicated by the history or physical examination:
a. Antinuclear antibody
b. Rheumatoid factor
c. Monospot
d. Chest x-ray
e. Colonoscopy
f. Sleep study
g. Urine analysis
3. Screening tests appropriate for age and gender should be performed.
IV. DIAGNOSIS
Fatigue is a very commonly encountered complaint. In most cases, a thorough history, physical,
and a limited number of ancillary tests reveal a more precise diagnosis. Fatigue is rarely the only
presenting symptom in cases of malignancy or connective tissue disease. Studies have shown that
TABLE 2.5.1 Common Causes of Fatigue
Medical conditions Psychiatric disorders Lifestyle factors
Hypothyroidism Major depressive disorder Sleep deprivation
Anemia Bipolar disorder Marital discord
Cardiomyopathy Alcoholism/substance abuse Job stress
COPD Anxiety Caring for young children
Morbid obesity Somatoform disorders Altered work schedule
Sleep disorders
Medication side effects
β-Blockers
Centrally acting α-blockers
Antidepressants
Subacute infections
Viral infections (CMV, EBV,
HIV)
Bacterial endocarditis
Malignancy
Fibromyalgia
COPD, chronic obstructive pulmonary disease; CMV, cytomegalovirus; EBV, Epstein-Barr virus; HIV,
human immunodeficiency virus.
Chapter 2 • Undifferentiated Problems
15
among patients with fatigue, approximately 40% have an underlying medical diagnosis, approxi-
mately 40% have a psychiatric diagnosis, and 12% have both medical and psychiatric explanations
for their fatigue. Approximately 8% of patients have no discernible diagnosis (2). If undiagnosed
fatigue persists for >6 months and meets the other criteria for CFS, that diagnosis is applied. If the
other criteria for CFS are not met, the term idiopathic chronic fatigue is used. Fatigue that cannot
be attributed to a medical or psychiatric diagnosis is often thought to be due to lifestyle factors.
REFERENCES
1. Centers for Disease Control and Prevention. Chronic fatigue syndrome. Accessed at National Center for
Infectious Diseases (www.cfs.general/index.html) on April 23, 2012.
2. Morrison JD. Fatigue as a presenting complaint in FP. J Fam Pract 1980;10:795–801.
3. Epstein KR. The chronically fatigued patient. Med Clin North Am 1995;79:315–327.
4. Craig T. Chronic fatigue syndrome: evaluation and treatment. Am Fam Physician 2002;65(6):
1083–1091.
2.6
Fever
Dorota Britz
I. BACKGROUND. Fever is defined as an elevation in core body temperature above the usual daily
range for an individual. It is generally accepted as core body temperature of or above 38°C
(100.4°F). Hyperpyrexia is extreme elevation of body temperature to above 41.5°C (106.7°F).
Fever may be a symptom of various disease processes. A fever without an immediately apparent
etiology is generally referred to as fever of unknown origin.
II. PATHOPHYSIOLOGY
A. Mechanism of Temperature Control.
The hypothalamus controls core body tempera-
ture. Elevated levels of Prostaglandin E2 (PGE2) in the hypothalamus cause it to reset the
body’s temperature control to a higher value. This phenomenon leads to peripheral vaso-
constriction causing less heat loss, and, if necessary to reach the new temperature goal set
by the hypothalamus, also more heat generation in muscles and liver, resulting in fever. In
contrast, during hyperthermia the thermostat in the hypothalamus is not reset.
B. Normal Temperature Variation. Normal body temperature varies by an average of 0.5°C
(0.9°F) during the course of the day. Body temperature is generally lowest in the morning
and the highest in the evening. Children tend to have higher body temperatures than the
elderly. Core temperature will also be higher after eating and for 2 weeks after ovulation.
C. Temperature Measurement. Rectal measurements are generally 0.6°C (1.0°F) higher
than oral (sublingual) readings.
III. EVALUATION
A. History.
Complete history is crucial to establishing the etiology of fever. Particular atten-
tion should be paid to the following components:
1. Duration and pattern of fever
2. Prescription or over-the-counter medications
3. Past surgeries, including any implanted devices, and any perioperative complications
4. Exposure to ill contacts
5. Travel, especially to foreign countries or remote/wilderness areas
6. Comprehensive review of systems, to include symptoms sometimes associated with fever, such
as weight loss, night sweats, cough, urinary symptoms, abdominal or joint pain, and rashes
7. Occupational exposures, especially to animals
8. Family history of illnesses such as malignant hyperthermia
16
Taylor’s DifferenTial Diagnosis Manual
B. Physical Examination.
1. Particular attention should be paid to skin, HEENT, chest, abdomen, and lymphatics.
2. Complete set of vital signs should be recorded, to include temperature, heart rate,
respiratory rate, and blood pressure. Fever is generally accompanied by tachycardia.
Hypotension may be a sign of sepsis.
C. Additional Testing. If the source of fever is not obvious from the history and physical
exam, the initial tests would generally include a complete blood count with manual differ-
ential, urinalysis, and chest x-ray. Oftentimes cultures of blood, urine, and sputum, as well
as testing for pelvic/genital infections may be performed as well. Possible infectious processes
within the central nervous system can be investigated with lumbar puncture and obtaining
studies of cerebrospinal fluid. Further radiographic studies may be warranted depending
on patient’s presentation. If these investigations for an infectious process do not yield sat-
isfactory results, further tests may be performed to look for connective tissue diseases with
measurements of antinuclear antibodies and rheumatoid factor.
IV. DIAGNOSIS
A. Acute Febrile Illness.
Most fevers in the outpatient setting present in the context of acute
viral illness. They generally last up to 7 to 10 days and can be treated symptomatically.
Common bacterial causes may include pharyngitis/tonsillitis, sinusitis, bronchitis, pneumo-
nia, and urinary tract infection.
TABLE 2.6.1 Most Common Etiologies of Fever of Unknown Origin in Adults
and Children
Adults Children
Infectious disease Infectious diseases
Tuberculosis Brucellosis
Occult abscess Cat scratch disease
Osteomyelitis Leptospirosis
Bacterial endocarditis Malaria
Sinusitis Tuberculosis
Dental abscess Salmonella infections
Connective tissue diseases Toxoplasmosis
Adult Still’s disease Tularemia
Giant cell arteritis Viral infections (CMV, EBV, adenovirus, hepatitis, enterovirus)
Malignancy Bone and joint infections
Drugs Endocarditis
Antibiotics, antimalarials Intra-abdominal abscess
Histamine blockers Liver infections
Anti-seizure medications Rotavirus
NSAIDs, antiarrhythmics Urinary tract infections
Antithyroid drugs Connective tissue disorders
Juvenile idiopathic arthritis
Neoplasms
Drugs
Kawasaki disease
CMV, cytomegalovirus; EBV, Epstein-Barr virus; NSAID, nonsteroidal anti-inflammatory drug.
Chapter 2 • Undifferentiated Problems
17