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The use of these biochemical markers is controversial due to concerns about intra-assay
and inter-assay variability. Further studies are needed to determine the clinical utility of
these markers in osteoporosis evaluation and management (7).
IV. DIAGNOSIS. Assessment of microarchitecture requires bone biopsy, which is not routinely
used in clinical practice. Therefore, BMD assessment is the gold standard to diagnose osteopo-
rosis (19).
The WHO has established the following definition and diagnostic criteria for osteopenia
and osteoporosis, based on BMD measurements in white women:
A. Osteopenia—BMD between 1 and 2.5 SD below the mean for young adult women (T-score
between –1 and –2.5)
B. Osteoporosis—BMD 2.5 SD or more below the normal mean for young adult females
(T-score at or below –2.5)
The diagnostic finding of low BMD is nonspecific and can have a multitude of etiologies
(see Section II Pathophysiology). An important fact to consider is that the clinical diagnosis
of osteoporosis may be made in the presence of a fragility fracture, without BMD measure-
ment (18).
RefeRences
1. Duque G, Troen BR. Chapter 117. Osteoporosis. In: Halter JB, Ouslander JG, Tinetti ME,
Studenski S, High KP, Asthana S, eds. Hazzard’s geriatric medicine and gerontology, 6th ed. New York,
NY: McGraw-Hill; 2009.
2. Manolagas SC. Pathogenesis of osteoporosis, Up-to-Date, August, 2012, Topic # 2044 version 8.0,
http://www.uptodate.com/contents/pathogenesis-of-osteoporosis?source=search_result&search=
pathogenesis+of+osteoporosis&selectedTitle=1%7E150
3. Xiong J, Onal M, Jilka RL, et al. Matrix-embedded cells control osteoclast formation. Nat Med
2011;17:1235–1241.
4. Manolagas SC. Birth and death of bone cells: basic regulatory mechanisms and implications for the
pathogenesis and treatment of osteoporosis. Endocr Rev 2000;21:115.
5. Manolagas SC, Kousteni S, Jilka RL. Sex steroids and bone. Recent Prog Horm Res 2002;57:385.
6. Lindsay R, Cosman F. Chapter 354. Osteoporosis. In: Longo DL, Fauci AS, Kasper DL, Hauser
SL, Jameson JL, Loscalzo J, eds. Harrison’s principles of internal medicine, 18th ed. New York, NY:
McGraw-Hill, 2012.
7. Dana Jacobs-Kosmin, MD, Sucharitha Shanmugam, MD; Chief Editor: Herbert S Diamond, MD.
Osteoporosis (Medscape).
8. [Guideline] American Association of Clinical Endocrinologists medical guidelines for clinical practice
for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates
for 2003. Endocr Pract Nov-Dec 2003;9(6):544–564. [Medline].
9. Kelman A, Lane NE. The management of secondary osteoporosis. Best Pract Res Clin Rheumatol Dec
2005;19(6):1021–1037. [Medline].
10. Greenspan SL, Korytkowski M, Resnick NM. Chapter 23. Geriatric endocrinology. In: Gardner DG,
Shoback D, eds. Greenspan’s basic & clinical endocrinology, 9th ed. New York, NY: McGraw-Hill, 2011.
11. Mann GB, Kang YC, Brand C, Ebeling PR, Miller JA. Secondary causes of low bone mass in
patients with breast cancer: a need for greater vigilance. J Clin Oncol Aug 1 2009;27(22):3605–3610.
[Medline].
12. Holick MF. Vitamin D deficiency. N Engl J Med Jul 19 2007;357(3):266–281. [Medline].
13. National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis.
Available at http://www.nof.org/professionals/clinical-guidelines. Accessed January, 2011.
14. Gosfield E 3rd, Bonner FJ Jr. Evaluating bone mineral density in osteoporosis. Am J Phys Med Rehabil
May-Jun 2000;79(3):283–291. [Medline].
15. Curtis JR, Carbone L, Cheng H, Hayes B, Laster A, Matthews R, et al. Longitudinal trends
in use of bone mass measurement among older Americans, 1999-2005. J Bone Miner Res. Jul
2008;23(7):1061–1067. [Medline]. [Full Text].
16. U.S. Preventive Services Task Force. Screening for Osteoporosis: U.S. Preventive Services Task Force
Recommendation Statement. Ann Intern Med Jan 17 2011;[Medline].
17. Michael K. Screening for osteoporosis, Up-to-Date, August, 2012
18. Rosen H, Drezner C. Diagnosis and evaluation of osteoporosis in postmenopausal women, Up-to-Date,
August, 2012.
19. Resnick D, Kransdorf M. Osteoporosis. In: Bone and Joint Imaging. 3rd ed. 2005:551.
408
Taylor’s DifferenTial Diagnosis Manual
18.5
I. BACKGROUND. A solitary pulmonary nodule (also referred to as a coin lesion) is a common
clinical problem (1). In lung cancer screening studies that enrolled individuals believed to be at
high risk for neoplasms of the lung, the prevalence of solitary pulmonary nodules varied from
8% to 51% (2). It is usually detected incidentally on a chest X-ray or computed tomographic
(CT) scan (3). A solitary pulmonary nodule is considered to be an isolated radiographic opacity
that is spherical and well circumscribed. It measures less than 3 cm in diameter, is surrounded
by aerated lung, and has no associated atelectasis, hilar enlargement, or pleural effusions. The
size at which a nodule becomes a mass is arbitrary, although 3 cm is typically used. The major
question that follows detection of a solitary pulmonary nodule is whether the lesion may be
malignant. Toward that end, the physician needs to determine which of the following three
approaches to use: observation with serial radiologic monitoring, biopsy, or immediate excision.
The ideal approach would result in definitive resection of all malignant nodules, while avoiding
resection of benign nodules that do not require therapy.
II. PATHOPHYSIOLOGY. Pulmonary nodules may be of either benign or malignant etiology. All
types of lung cancer may present initially as a solitary nodule, including primary lung cancer, carci-
noid tumors, and metastases. Benign causes include infections (i.e., granuloma, bacterial infection,
abscess), benign neoplasms (i.e., hamartoma, hemangioma), congenital causes (i.e., bronchogenic
cyst), and other causes (i.e., amyloid, sarcoidosis, rheumatoid arthritis, rib fracture) (4, 5).
III. EVALUATION
A. History.
History is not definitive but can assist in moving the odds toward benign or
malignant. The probability of a solitary pulmonary nodule being malignant rises with
increasing patient age. Being younger than 40 years carries a less than 3% chance of malig-
nancy, whereas being older than 60 years carries a greater than 50% chance of malignancy.
Other risk factors for lung cancer include a history of smoking, asbestos exposure, family
history, and previously diagnosed malignancy. Radiographic features can also be used to help
predict whether a nodule is malignant. A lesion larger than 2 cm carries 50% likelihood
that it is malignant (6). Review of prior imaging studies can reveal important information
regarding growth. Lesions that are malignant tend to have a volume doubling time between
20 and 400 days, where volume doubling of a nodule corresponds to an approximately
30% increase in its diameter (3). Benign lesions either have a very rapid growth rate, with a
doubling time of less than 20 days seen in infectious conditions, or extremely long doubling
times. A nodule that has been present and unchanged for 2 years is almost certain to be
benign.
B. Physical Examination. The presence of fever suggests a possible infectious etiology.
Extrapulmonary manifestations of certain diseases, such as tuberculosis, sarcoidosis, or rheu-
matoid arthritis, may give some additional clues to the diagnosis. However, the contribution
of physical diagnosis is limited.
C. Testing. If the nodule is detected on plain X-ray, then subsequent additional studies
can include CT scan, fiber-optic bronchoscopy, percutaneous needle aspiration or biopsy,
positron emission tomography (PET), and thoracoscopy (also called video-assisted thoracic
surgery [VATS]) or thoracotomy for excision. Magnetic resonance imaging is not indicated
in the evaluation of a solitary pulmonary nodule (5).
1. A CT scan can be useful in that a small nodule not seen on plain X-ray may be detected
by it. The presence of multiple nodules favors a benign cause, except with the history of
prior neoplasm, in which case metastatic disease is more likely. A stippled or eccentric
Solitary Pulmonary
Nodule
Scott Ippolito
Chapter 18 • Diagnostic Imaging Abnormalities
409
pattern of calcification within the nodule favors malignancy, whereas other characteristic
patterns may favor a benign etiology (5). Malignant lesions tend to have more irregular
and spiculated borders, whereas benign lesions often have relatively smooth and discrete
borders. Nodules that have a ground glass appearance on CT are frequently malignant,
with studies of such nodules indicating that approximately 20–60% are malignant (5).
Benign lesions tend to have higher Hounsfeld units on CT scan, a measure of density,
although there is no distinct cutoff point between benign and malignant lesions.
2. Fiber-optic bronchoscopy is a useful procedure for the diagnostic evaluation of large,
central nodules and masses; however, it is much less useful for small solitary pulmonary
nodules and for peripheral masses. The yield for diagnosing peripheral lesions smaller
than 2 cm by brushing or transbronchial biopsy is 33%, whereas the yield for peripheral
lesions greater than 2 cm is 62%. Fluoroscopy or endobronchial ultrasound, where avail-
able, can be used to optimize localization of the lesion and increase the yield to greater
than 70%.
3. Percutaneous needle aspiration (also called fine needle aspiration) can be performed
through the chest wall using either fluoroscopy or CT scanning to guide the placement
of the needle within the lesion. Material for cytology is obtained, but there is no biopsy
of a core of tissue. It has a diagnostic yield of 60% for peripheral nodules smaller than
2 cm and 64% for peripheral nodules smaller than 3 cm. It is more helpful for confirm-
ing malignancy rather than establishing a specific benign diagnosis and can be compli-
cated by pneumothorax (7).
4. Percutaneous needle biopsy can be performed to obtain a core of tissue by using a cutting
needle, thereby improving the diagnostic yield of benign nodules. An increasing number
of centers are performing this procedure, but complications include hemorrhage and
pneumothorax, which occur in 1% and 15% of biopsies, respectively (8).
5. PET, with flurodeoxyglucosse (FDG) used as a biological marker, can help distinguish
malignant and benign lesions because cancers are metabolically active and take up FDG
avidly. False-positive results can be seen in metabolically active nodules such as infectious
granulomas and inflammatory conditions (9). False-negative results can occur because
of the limited resolution of PET, which can form an image only down to approximately
8 mm, thereby possibly not detecting malignancies smaller than about 1 cm. In addition,
some tumors, such as carcinoid and bronchoalveolar carcinoma, have very low metabolic
rates and can be missed (10). An added benefit of PET is the acquisition of staging data
if the nodule is malignant.
6. VATS can be performed as a method of surgical excision if the lesion is located close
enough to the pleural surface. Alternatively, thoracotomy, which has greater morbidity,
can be performed. The advantage of VATS and thoracotomy is that the procedures are
both diagnostic and therapeutic. However, they are more invasive with inherent compli-
cations of hemorrhage and pneumothorax.
IV. DIAGNOSIS. The initial diagnosis of solitary pulmonary nodule is usually made through plain
X-ray or CT. The differential diagnosis includes primary or metastatic lung malignancy. Further
evaluation and monitoring depends on the clinical setting. Wherever possible, obtain old imag-
ing studies for comparison. A nodule that has clearly grown on serial imaging tests should be
excised (5). A nodule unchanged over a period of 2 years is almost certain to be benign. There is
significant variation regarding what is considered optimal initial management; however, there is
general consensus that management should be individualized. One approach uses the designa-
tion of low, intermediate, or high probability of malignancy based upon the clinician’s overall
impression, after consideration of all clinical and radiographic features.
A. A nodule that has a low probability of being malignant can be followed with serial CT
scans. (CT scans are preferable to chest X-rays because growth is more readily detectable.
Specifically, 3 to 5 mm of growth is necessary for detection on a chest X-ray, compared with
only 0.5 mm on a high-resolution CT [3]).
B. A nodule that is smaller than 1 cm and has an intermediate probability of being malignant
can be followed by serial CT scans.
410
Taylor’s DifferenTial Diagnosis Manual
C. A nodule that is 1 cm or larger and has an intermediate probability of being malignant
should be evaluated by PET. Nodules that are negative on PET can be followed with serial
CT scans, while nodules that are positive should be excised.
D. A nodule that has a high probability of being malignant should be excised.
The following guidelines, proposed by the Fleischner Society, advocate different fre-
quencies for serial CT scans based upon the size of the nodule and the patient’s risk for
lung cancer (6). Patients are considered low risk if they have no history or minimal history
of smoking and other risk factors; otherwise, they are considered high risk.
1. For nodules less than 4 mm, serial CT scans are not required if the patient is of low risk.
Patients who are of high risk should have a CT performed at 12 months, with no further
follow-up if the nodule is unchanged.
2. For nodules of 4–6 mm, a CT should be performed at 12 months if the patient is of
low risk, with no further follow-up if the nodule is unchanged. Patients who are of high
risk should have a CT performed at 6–12 months and at 18–24 months if the nodule is
unchanged.
3. For nodules 6–8 mm, a CT should be performed at 6–12 months and at 18–24 months
if the nodule is unchanged and the patient is of low risk. Patients who are of high risk
should have a CT at 3–6, 9–12, and 24 months if the nodule remains unchanged.
4. For nodules greater than 8 mm, a CT should be performed at 3, 6, 9, and 24 months if
the nodule remains unchanged, regardless of whether the patient is of low or high risk.
Consultation with a pulmonologist is warranted to decide whether and how the
nodule should be sampled if the clinical features and radiologic features do not provide
sufficient evidence that a lesion is either benign or malignant. Sampling of the nodule can
be performed through the airway (bronchoscopy) or through the chest wall (percutaneous
needle aspiration or biopsy).
RefeRences
1. Libby DM, Smith JP, Altori NK, et al. Managing the small pulmonary nodule discovered by CT.
Chest 2004;125:1522.
2. Wahidi NM, Govert JA, Goudar RK, et al. Evidence for the treatment of patients with pulmonary
nodules: when is it lung cancer? ACCP evidence-based clinical practice guidelines, 2nd ed. Chest
2007;132:94S.
3. Ost D, Fein AM, Feinsilver SH. Clinical practice. The solitary pulmonary nodule. N Engl J Med
2003;348:2535
4. Winer-Muram HT. The solitary pulmonary nodule. Radiology 2006 Apr;239(1):34–49.
5. Gould MK, Fletcher J, Iannattoni MD, et al. American College of Chest Physicians. Evaluation of
patients with pulmonary nodules: when is it lung cancer? ACCP evidence based clinical practice
guidelines, 2nd ed. Chest 2007;132:108S–130S.
6. MacMahon H, Austin JH, Gordon G, et al. Guidelines for management of small pulmonary nodules
detected on CT scans: a statement from the Fleischner Society. Radiology 2005;237:395.
7. Ost D, Fein A. Evaluation and management of the solitary pulmonary nodule. AM J Respir Crit Care
Med 2000:162:782.
8. Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after
transthoracic needle lung biopsy of a pulmonary nodule; an analysis of discharge records. Ann Intern
Med 2011;155:137.
9. Vansteenkiste JF, Stroobants SS. PET scanning in lung cancer: current recommendation and innova-
tion. J Thorac Oncol 2006;1:71.
10. Gould MK,, Maclean CC, Kushner WG, et al. Accuracy of positron emission tomography in the
diagnosis of pulmonary nodules and mass lesions: a meta-analysis. JAMA 2001;21:914–924.
Chapter 18 • Diagnostic Imaging Abnormalities
411
Note: Page numbers followed by f indicate figures; those followed by t indicate tables.
Index
A
Abdomen
pain, 173–176. See also Pain, abdominal
postmenopausal bleeding, 260
Abetalipoproteinemia, 213
Abscess, pharyngitis, 100, 101, 102
Absorptiometry, dual energy x-ray, 407
AC syndromes, shoulder pain, 292
Acoustic neuroma, 8t
Acquired immunodeficiency syndrome
(AIDS), 41, 43
Action tremor, 64, 65
Acute angle closure glaucoma, 82, 83–85
Acute cough, 148, 150
Acute kidney injury (AKI), 228, 377
Acute pericarditis (AP), 142
Acute phase protein response, 348
Acute stress disorder (ASD), 36
Adhesive capsulitis, shoulder pain, 292
Adie’s pupil, pupillary inequality, 82
Adjustment disorder with depressed
mood, 42
Adjustment reaction, 37
Adrenal insufficiency, 347
Age factors
androgenetic alopecia, 294
arthralgia, 266
breast mass, 244
falls, 11
hypertension, 136
lymphadenopathy
generalized, 335, 336
localized, 337
menorrhagia, 251
nystagmus, 76, 77
pharyngitis, 100
pulmonary nodule, solitary, 409, 410
vertigo, 111
vesicular and bullous eruptions, 310–311
Vitamin D deficiency, 333
Alcoholism
ascites, 177
ataxia, 47
bipolar disorder, 38
dementia, 54
dysphagia, 190
halitosis, 91
hepatitis, 200
weight loss, unintentional, 33
Aldosteronism, 138
Alkaline phosphatase elevation, 358
causes of, 358
diagnosis of, 359t
5´-nucleotidase testing, 358
Allergic reaction
eosinophilia, 346, 347
stridor, 169
Alopecia, 294–296
causes of, 294
differential diagnosis of, 296
epidemiology of, 295
generalized, 294
history of, 295
human immunodeficiency virus, 296
localized, 295
moth eaten pattern, 295
nonscarring, 294
physical examination for, 295
pull test, 295
scarring, 294
testing, 295
Alopecia areata, 294
Alzheimer’s disease
dementia, 53
diagnosis of, 54
nocturia, 226
Amenorrhea, 242–243
causes of, 242
diagnosis of, 242
history of, 241
physical examination for, 243
primary, 242
secondary, 242
testing, 243
Aminotransferase elevation, 363–368
diagnosis of, 364t
Amnestic disorders, 56
Amyloidosis, 213
Androgenetic alopecia, 294
Androgens, gynecomastia, 316
Anemia, 344–346, 345t
blood loss, 344
causes of, 344, 345–346
diagnosis of, 345
history of, 344
macrocytic, 345t, 346
microcytic, 345, 345t
normocytic, 346
physical examination for, 344
splenomegaly, 342
testing, 345
Angina, congestive heart failure, 128
Angiography
gastrointestinal bleeding, 200
412
splenomegaly, 342
tinnitus, 109
Anisocoria, 81
physiologic, 81
Anorexia, 5–7
causes of, 5
diagnosis of, 7
history of, 6
medication and habits, 6
pathologic factors, 5
pharmacologic factors, 5
physical examination for, 6
psychiatric factors, 5
social factors, 6
testing, 6
Anoscopy
rectal bleeding, 212
urethral discharge, 241
Anterior cruciate ligament (ACL), 274t
Anterior ischemic optic neuropathy, 80
Anticoagulation
diagnosis of, 117
history of, 117
physical examination for, 117
physiologic targets of, 116t
primary hemostasis, 116
secondary hemostasis, 116
testing, 117
treatment of, 117t
Anti neutrophil cytoplasmic antibody
(ANCA), 47
Antinuclear antibodies, 368–372
diagnosis of, 364t
Anuria. See Oliguria and anuria
Anxiety, 35–37
causes of, 35
differential diagnosis of, 36
epidemiology of, 35
history of, 35
physical examination for, 36
psychologic symptoms of, 35
social phobia, 37
specific phobia, 36
testing, 36
Aortic regurgitation (AR), 130
causes of, 130
epidemiology of, 130
Aortic stenosis, heart murmur, systolic, 134t
Appetite, loss of. See Anorexia
Argyll Robertson pupils, 82
Arnold-Chiari malformation, nystagmus, 76
Arterial blood gases (ABG)
cyanosis, 152
pneumothorax, 162
Arteriovenous fistula, 107
Arteritis, 73
Arthralgia, 265–267
causes of, 265
differential diagnosis of, 266, 267t
history of, 265
physical examination for, 266
testing, 266
Arthrography, shoulder pain, 292
Ascites, 176–179
causes of, 176
differential diagnosis of, 177
history of, 177
paracentesis findings, 178t
physical examination for, 177
testing, 177
Asherman’s syndrome, 243
Asthma, cyanosis, 151–153
Asynergia, ataxia, 46
Ataxia, 46–47
causes of, 47
diagnosis of, 47
dominant, 47
Friedreich, 47
FXTAS, 47
genetic, 47
laboratory tests, 46
recessive, 47
sporadic, 47
testing, 47
Ataxic dysarthria, 46
Atopic dermatitis, 83
Atrial fibrillation, tachycardia, 146
Atrial flutter, tachycardia, 146
Atrial myxoma, 131
Atrioventricular block, bradycardia, 122
Audiography, 93
Audiometry, 109
Auscultation
heart murmur, systolic, 133
pericardial friction rub, 146
Autoimmune disorders
cyanosis, 152
eosinophilia, 347
hepatitis, 201
stomatitis, 105, 106
thyroid disease, 323, 330
B
Back pain, low, 276–279
causes of, 276t
diagnosis of, 279
disc herniation, 278t
history of, 276
physical examination for, 277
Index
413
Back pain, low (continued )
red flags, 276, 277t
testing, 278
Bacterial overgrowth
halitosis, 91
steatorrhea, 213, 214, 215
Barium tests, dysphagia, 193
Behçet’s disease, stomatitis, 105, 106
Bicipital tendonitis, shoulder pain, 292
Bilateral occipital lobe damage, 75
Bilirubin, 208
Binocular visual loss
partial, 74
total, 72
Biopsy
alopecia, 295
breast cancer, 399
breast mass, 244
dysphagia, 193
hematuria, 219
liver, hepatitis, 203
lymphadenopathy, generalized, 336
lymphadenopathy, localized, 338
mediastinal mass, 404
postmenopausal bleeding, 261
pruritus, 306
pulmonary nodule, solitary, 409, 410
stomatitis, 106
thyroid nodules, 329
urticaria, 309
vesicular and bullous eruptions, 312
Bipolar disorder, 37–39
causes of, 37
depression, 42
depressive symptoms, 38
differential diagnosis of, 39
epidemiology of, 38
history of, 38
manic symptoms, 38
physical examination of, 38
testing, 39
triggering factors, 38
Bleeding
female reproductive system. See Female
reproductive system
gastrointestinal, 197–200
causes of, 198t
complete blood count, 198
differential diagnosis of, 200
hematemesis, 198
history of, 198
liver function tests, 198
melena, 198
partial thromboplastin time, 198
physical examination for, 198
prothrombin time, 198
testing, 198
uncommon causes of, 199t
intracranial, headache, 19
petechiae and purpura, 339
rectal, 210–212
diagnostic procedures, 211
differential diagnosis of, 211
history of, 211
testing, 211
thrombocytopenia, 359
Blepharitis, 83, 85
Blind spot. See Scotoma
Blisters. See Vesicular and bullous eruptions
Blood gases. See also Laboratory tests
delirium, 52
Blood pressure, 135
diastolic, 135
hypertension, 135, 137
systolic, 135
Bone cyst, 400–401
causes of, 400
diagnosis of, 401
epidemiology of, 400
history of, 401
physical examination for, 401
testing, 401
x-ray, 401
Bone mineral density (BMD), 407
Bone scan
hip pain, 272
lower back pain, 279
osteopenia, 407
Bradycardia, 121–123
cardiac risk factors, 122
causes of, 121
differential diagnosis of, 122
epidemiology of, 122
history of, 122
physical examination for, 122
testing, 122
types of, 122
Brain disorders
ataxia, 46
tumors, headache, 19
Brain natriuretic peptide (BNP), 373–375,
374t
cardiac inflammation, 375
chest pain, 375
congestive heart failure, 128, 373, 375
coronary ischemia, 375
diagnosis of, 373
left ventricular dysfunction, 373, 374
obese patients, 372
patients with cirrhosis, 375
414
Index
patients with renal failure, 375
uses of, 375
Brain stem function, coma, 48
Branch retinal artery occlusion, 73, 74
Branch retinal vein occlusion (BRVO), 73
Breast cancer
causes of, 397
diagnosis of, 399
ductal carcinoma, 397
epidemiology of, 398
gynecomastia, 317
history of, 398
lobular carcinoma, 397
physical examination for, 398
risk factors for, 398
testing, 399
types of, 397
Breast history, breast mass, 244
Breast mass, 243–245
causes of, 243
epidemiology of, 244
history of, 244
physical examination for, 244
testing, 244
Breath, shortness of, 163–166
causes of, 164t
congestive heart failure, 165
diagnosis of, 166
hepatojugular reflux, 165
history of, 164
neuromuscular disorder, 166
physical examination for, 165
testing, 166
Breathing patterns, coma, 50t
Bronchoscopy
cough, 150
hemoptysis, 155
pleural effusion, 157
pneumothorax, 161
pulmonary nodule, solitary, 409, 410, 411
wheezing, 172
Bruits, tinnitus, 107
C
C-reactive protein (CRP), 348–350
diagnosis of, 349
physical examination for, 348
risk of cardiovascular disease, 350t
testing, 348
Café au lait macules, 304
Calcific tendonitis, shoulder pain, 292
Calf pain, 267–269
diagnosis of, 269
differential diagnosis of, 268t
history of, 268
physical examination for, 269
testing, 269
Cancer
breast, 397–399
breast mass, 243, 244, 245t
cervical, 256, 258
eosinophilia, 347
gynecomastia, 317
lymphadenopathy, generalized,
335, 336
menorrhagia, 252, 253
nipple discharge, 255
postmenopausal bleeding, 260
rectal bleeding, 211, 212
scrotal mass, 234, 235
scrotal pain, 236
thyroid enlargement/goiter, 327
thyroid nodules, 328, 329f
weight loss, unintentional, 32
Cardiac catheterization, congestive heart
failure, 128
Cardiac stress test, 119
Cardiomegaly, 123–125
arrhythmias, 124
causes of, 123
differential diagnosis of, 124
epidemiology of, 123
family history, 123
history of, 123
hypertension, 123, 124
medical history, 123
physical examination for, 124
social history, 123
testing, 124
Cardiothoracic ratio (CTR), 123
Cardiovascular system
in anorexia, 6
anticoagulation, 116–118
bradycardia, 121–123
cardiomegaly, 123–125
chest pain, 118–120
atypical, 114–115
congestive heart failure, 125–128
heart murmurs
diastolic, 129–132
systolic, 132–134
hypertension, 135–139
palpitations, 139–141
pericardial friction rub, 142–143
Raynaud’s disease, 144–145
tachycardia, 145–147
Celiac disease, 213, 215
Cellulitis, 269
Central cyanosis, 151
Index
415
Central retinal vein occlusion
papilledema, 80
visual loss, 74
Central scotoma, 86, 87, 89
causes of, 87t
Cerebrospinal fluid (CSF)
ataxia, 47
coma, 48
dementia, 55
maculopapular rash, 300
papilledema, 80
Cervical cytopathology, 258
Cervical dysplasia, history of, 257t
Cervical neoplasia, risk factors for, 257
Cervical radiculopathy, 292
Chalazion, 83
Chédiak-Higashi syndrome, nystagmus, 77
Chemotherapy
alopecia, 294
anemia, 344
neutropenia, 352
osteoporosis, 406
stomatitis, 105, 106
thrombocytopenia, 356
Chest pain, 118–120
acute myocardial infarction, 114
atypical, 114–115
diagnosis of, 115
differential diagnosis of, 115
history of, 114
physical examination for, 114
testing, 114
chest x-ray, 115, 119
diagnosis of, 119
differential diagnosis of, 119, 120t
echocardiogram, 115, 119
electrocardiogram (ECG), 115, 119
history of, 119
laboratory tests, 115, 119
myocardium, 118
physical examination for, 119
risk factors for, 114
subendocardial infarction, 115
testing, 119
ventilation–perfusion scan/spiral CT scan of
the chest, 119
Chest x-ray
anorexia, 6
cardiomegaly, 124
chest pain, 115, 119
congestive heart failure, 128
fatigue, 15
hoarseness, 96
hypertension, 139
pleuritic pain, 159
pneumothorax, 161
shortness of breath, 166
weight loss, unintentional, 33
wheezing, 172
Children
ataxia, 47
bone cyst, 400
brain natriuretic peptide, 373
cough, 149
cyanosis, 151
diabetes mellitus, 313, 314, 315
diarrhea, 183, 184, 185
diplopia, 70
falls, 11
fever, 16, 17t
gynecomastia, 316
hoarseness, 95
Kawasaki’s disease, 301
knee pain, 273
lymphadenopathy, localized, 337
mediastinal mass, 403
neutropenia, 351
nosebleed, 98
nystagmus, 76, 77
oliguria and anuria, 228
osteoposis, 405
petechiae and purpura, 340
pharyngitis, 99, 101
proteinuria, 354
scrotal pain, 236, 237
seizures, 61
stridor, 167, 169
suicide risk, 43
thrombocytopenia, 356
urethral discharge, 239
vesicular and bullous eruptions, 310
Vitamin D deficiency, 333, 334
wheezing, 170, 171t
Chronic fatigue syndrome (CFS), 14
causes of, 14, 15t
Chronic obstructive pulmonary disease
(COPD), 148, 163, 171
Chronic pancreatitis, 213, 215
Chronic small bowel ischemia, 213
Chronology, seizures, 61
Circadian rhythm, insomnia, 24
Clinical breast exams (CBE), 398
Clonal disease, 347
Clumsiness, ataxia, 46
Coarctation of the aorta, 139
Coin lesions. See Pulmonary nodule
Colonoscopy, 15, 181, 200, 211, 212
Color Doppler, scrotal pain, 237
Collateral ligaments, knee pain, 273
Colposcopy, pap smear abnormality, 258
416
Index
Coma, 48–50
differential diagnosis of, 48
FOUR score, 48, 49t
Glasgow scale, 48, 49t
history of, 48
physical examination for, 48
testing, 48
Compartment syndrome, 268, 269
acute, 269
Complete heart block, 122, 129f, 131
Computed tomography (CT)
abdominal pain, 175
in anorexia, 6
arthralgia, 266
ataxia, 47
blurred vision, 67
bone cyst, 401
chest pain, 115, 119
coma, 48
corneal foreign body and corneal abrasion, 69
cyanosis, 152
delirium, 52
dementia, 55
diplopia, 71
dyspnea, 166
falls, 12
headache, 20
hearing loss, 94
hemoptysis, 155
hepatomegaly, 206
hip pain, 272
joint pain, monoarticular, 281
lower back pain, 279
mediastinal mass, 402, 404
menorrhagia, 253
nausea and vomiting, 26
neck pain, 284
nosebleed, 98
nystagmus, 78
oliguria and anuria, 231
osteoporosis, 407
papilledema, 80
pleuritic pain, 159
pneumothorax, 162
polycythemia, 353
pulmonary nodule, solitary, 409, 410, 411
pupillary inequality, 81
red eye, 84
rhinitis, 104
scotoma, 89
seizures, 62
shortness of breath, 166
shoulder pain, 292
splenomegaly, 342
steatorrhea, 215
stomatitis, 106
stridor, 169
stroke, 63
thyroid enlargement/goiter, 327
thyroid nodules, 329
tinnitus, 109
venous thromboembolism, 382
visual loss, 74
Conductive hearing loss (CHL), 92
Congestive heart failure (CHF), 125–128,
148, 373
causes of, 126, 126t
epidemiology of, 126
history of, 127
physical examination for, 127
testing, 127
types of, 126t
Conjunctivitis, 83–86
Consciousness, 48
Constipation, 179–183
causes of, 180, 180t
epidemiology of, 180
functional, 180t, 181
differential diagnosis of, 181t
history of, 181, 182t
idiopathic, 181
physical examination for, 181, 182t
Rome III criteria, 180t
testing, 181
Contact dermatitis, 83
Contact lenses
corneal abrasion, 68
red eye, 84
Continuous-loop event recorder,
palpitations, 141
Continuous murmur, 129, 131
causes of, 132
patent ductus arteriosus, 129f
Core needle biopsy, breast mass, 244
Corneal abrasion, 68, 83, 86
causes of, 68
history of, 68
physical examination for, 69
risk factors for, 68
Corneal foreign body, 68–69, 83
Cough, 148–150
acute, 148
bronchitis, 148
characteristics of, 148
in children, 149
chronic, 149
differential diagnosis of, 150
history of, 148
physical examination for, 149
testing, 149
Index
417