DIFFERENTIAL DIAGNOSIS
M Jalil Hanafi
MSMIT
“ ‘’The future belongs to those
who believe in the beauty of
their dreams”
-Eleanor Roosevelt
WHAT IS DIFFERENTIAL
DIAGNOSIS?
A systemic method of diagnosing a disorder
(e.g headache) that lacks unique symptoms or
signs
Systemic method used to identify unknowns
The process of identifying a condition by
comparing the signs and symptoms of all
pathologic processes that may produce similar
signs and symptoms
Static Process
Patient Encounter
Physical
History
Examination
Differential Diagnosis
Diagnostic Testing
Final Diagnosis
Dynamic Process
History Physical Examination
Differential Diagnosis
Where do you begin?
INFORMATION USE
AVAILABLE
Age
Gender Complaint
Vital signs
Differential
THOUGHT
Epidemiology PROCESS
diagnosis
History &
Physical Problem list
Examination
Final
diagnosis
CASE SCENARIO:
25 years old male with “cough, fever, headache, tired’’
COUGH FEVER HEADACHE TIRED
Infection Autoimmune Vascular Nutrition
Trauma Infection Exposure Metabolic
Congenital Inflammation Neoplasm Infection
Exposure Endocrine Neurologic Endocrine
Neoplasm Neoplasm Psychogenic Exposure
Neurologic Metabolic Infection Neoplasm
Psychogenic Exposure Trauma Autoimmune
CLINICAL
PRESENTATIO
NS
ABDOMINAL PAIN
May be:
[Link]
[Link] (lasting for
more than a few
days or presenting
intermittently)
CAUSES:
Gastrointestinal Urinary Tract Gynaecological
Vascular Peritoneum Abdominal wall
Retroperitoneum Referred pain Medical causes
GASTROINTESTINAL
CAUSES:
• Gastroduodenal
• Intestinal
• Hepatobiliary
• Pancreatic
• Splenic
URINARY TRACT:
• Cystitis
• Acute retention of urine
• Acute pyelonephritis
• Ureteric colic
• Hydronephrosis
• Tumour
• Pyonephrosis
• Polycystic kidney
GYNAECOLOGICAL:
• Ruptured ectopic pregnancy
• Torsion of ovarian cyst
• Ruptured ovarian cyst
• Salpingitis
• Severe dysmenorrhoea
• Mittelschmerz
• Endometriosis
• Red degeneration of a fibroid
VASCULAR
• Aortic aneurysm
• Mesenteric embolus
• Mesenteric angina
(claudication)
• Mesenteric venous
thrombosis
• Ischaemic colitis
• Acute aortic dissection
PERITONEUM
• Secondary peritonitis
• Primary peritonitis
ABDOMINAL WALL
• Strangulated hernia
• Rectus sheath haematoma
• Cellulitis
RETROPERITONEUM
• Retroperitoneal haemorrhage, e.g.
anticoagulants
REFERRED PAIN
• Myocardial infarction
• Pericarditis
• Testicular torsion
• Pleurisy
• Herpes zoster
• Lobar pneumonia
• Thoracic spine disease, e.g. disc,
tumour
MEDICAL CAUSES
• Hypercalcaemia
• Uraemia
• Diabetic ketoacidosis
• Sickle cell disease
• Addison’s disease
• Acute intermittent porphyria
• Henoch–Schönlein purpura
• Tabes dorsalis
Defecation
Age
Fever
History
PAIN (time & mode,
character, severity,
Past history
location, radiation
etc)
EXAMINATION:
General:
Is the patient lying comfortably? Is the patient
lying still but in pain, e.g. peritonitis? Is the
patient writhing in agony, e.g. ureteric or biliary
colic? Is the patient flushed, suggesting pyrexia
Pulse, temperature, respiration
Cervical lymphadenopathy
Chest
Abdomen (inspection, palpation,
auscultation and percussion)
Rectal examination
Vaginal examination
GENERAL INVESTIGATIONS
FBC, ESR (Hb peptic ulcer disease, malignancy. WCC infective/ inflammatory disease, e.g.
appendicitis, diverticulitis. ESR Crohn’s disease, TB.)
U&Es
Urea and creatinine
LFTs (Abnormal in cholangitis and hepatitis. Often abnormal in acute cholecystitis.)
Serum amylase
MSU
Blood, protein, culture positive in pyelonephritis. Red cells in ureteric colic
CXR (Gas under diaphragm (perforated viscus). Lower lobar pneumonia (referred pain).
AXR (Obstruction – dilated loops of bowel. Site of obstruction. Local ileus (sentinel loop) – pancreatitis,
acute appendicitis. Toxic dilatation – dilated, featureless, oedematous colon in ulcerative colitis or Crohn’s
disease. Renal calculi.)
Ultrasound (Localised abscesses, e.g. appendix abscess, paracolic abscess in diverticular disease. Free
fluid – peritonitis, ascites. Aortic aneurysm. Ectopic pregnancy. Ovarian cyst. Gallstones. Empyema,
SPECIFIC INVESTIGATION
Blood glucose
Serum calcium
Sickling test (sickle cell disease)
CRP (Crohn’s disease)
OGD (Peptic ulcer. Malignancy)
IVU (Stones. Obstruction.)
Barium enema (Carcinoma. Volvulus. Intussusception.)
Small bowel enema (Small bowel Crohn’s disease. Lymphoma of small bowel. Carcinoma of small bowel.)
Duplex Doppler
CT (Aneurysm. Pancreatitis. Tumour)
MRCP (Biliary tract disease)
Angiography (Superior mesenteric embolus or thrombosis)
VDRL (Syphilis)
Urinary porphobilinogens (Acute intermittent porphyria)
ABGs (Metabolic acidosis, e.g. uraemia, infarcted bowel, sepsis, diabetic ketoacidosis)
bHCG (Pregnancy. Ectopic pregnancy)
CASE STUDIES
CASE NO. 1:
• A 32-year-old male with no significant past medical history presents to the emergency
department with abdominal pain. He states the pain began a few days ago in the right
lower quadrant of the abdomen and now feels as though it is spreading to the mid-
abdomen.
• He describes the pain as coming on suddenly and sharp in nature. Since the onset, his
pain started to improve until the morning of his presentation to the emergency
department, when it acutely worsened. He says that the pain is much worse with
movement. The patient complaints of melena from past few days.
• The patient is concerned about a possible hernia as he does heavy lifting at work.
Review of systems is negative, including no anorexia, no nausea or vomiting, no
testicular pain or swelling, no urinary or bowel complaints, and no fevers or chills.
• The patient denies prior abdominal surgeries. He does smoke a
half pack of cigarettes a day, drinks alcohol socially, and denies
any recreational drug use. He notes no inherited medical
conditions in his family.
Vital signs on arrival:
• Blood pressure (BP) 120/73
Temperature: 35.6 C
• Heart rate (HR) 60 Oxygen saturation: 98%
• RR 18
Physical Exam
1. General: Alert and oriented, in no apparent distress, although ambulates into the emergency
room holding his abdomen.
2. HEENT: Normocephalic, atraumatic, sclera anicteric. Mucus membranes are moist.
3. Cardiovascular (CV): Regular rate and rhythm, no murmurs, rubs, gallops
4. Pulmonary: clear to auscultation bilaterally
1. Abdomen: moderate tenderness to palpation in the right lower quadrant
without rebound, guarding, or rigidity. Bowel sounds are present
throughout. Negative psoas and obturator signs.
2. Genitourinary (GU): genitalia examined in a standing position with a
normal external exam, no masses felt with a cough, intact cremasteric reflex
3. Back: No cerebrovascular (CVA) tenderness
4. Neurological: No focal deficits
5. Skin: Warm and dry, no rashes
Radiological sign:
• A CT scan with intravenous contrast was
ordered. This was interpreted by the radiologist
noting a blind ending.
• The inflamed appendage is emanating from the
small bowel, with an incomplete superior wall and
fluid layering in the deep pelvis.
The possible differential diagnosis for this case scenario
could be:
1) Appendicitis
2) Typhlitis
3) Epiploic appendagitis
4) Perforated viscous
5) Inflammatory bowel disease, Meckel’s diverticulum
6) Small bowel obstruction
7) Testicular torsion
8) Epididymitis
9) Hernia
10) Urinary tract infection
11) Pyelonephritis.
DIAGNOSIS:
Meckel’s Diverticulum
As the patient complaints of melena
and abdominal pain. And CT scan is
suggestive of inflamed appendage
emanating from the small bowel.
CASE NO. 2:
• A 45-yr-old man comes to the emergency department because of a 6-h
history of acute-onset left-sided lower abdominal pain.
• He describes the pain as starting over his left flank and radiating down
toward his groin. The pain comes and goes but is intense when present. He
has had some mild nausea without vomiting. The pain does not change with
eating. The pain is less when he walks around than when he sits or lies
down flat.
• He has not had any bloody stools, black stools, or change in bowel habits.
He denies having diarrhea and constipation. He has noticed his urine looks
"dark" but denies pain during urination and urinary frequency.
• He says that he swims several times a week for exercise, and this
pain started immediately after swimming.
• He also notes that several days ago, his son ran into his left side
while playing football. He took some acetaminophen, which
minimally relieved his discomfort.
• He now presents for evaluation at the emergency department because
the pain has not subsided. He says he has never experienced pain like
this.
1) Skin: Denies rashes, itching, and any lesions.
2) HEENT: Noncontributory
3) Pulmonary: Noncontributory
4) Cardiovascular: Denies palpitations and chest pain. No lower-
extremity edema.
5) Gastrointestinal: Reports nausea when pain is at its most intense
but no vomiting. No constipation or diarrhea. Last bowel movement
yesterday; no hematochezia or melena. No appetite; he has not
eaten since the pain began.
6) Genitourinary: No dysuria, hematuria, urinary frequency or
urgency, or increased volume of urine. States urine appears "dark."
7) Musculoskeletal: Occasional low back pain with strenuous activity
8) Neurologic: Noncontributory
9) Psychiatric: Noncontributory
• Medical history: Diabetes mellitus since his 20s that is well-controlled
with oral drugs, diet, and exercise. Hypertension and hyperlipidemia both
well-controlled on drugs. Obstructive sleep apnea for which he uses a
CPAP machine. Recent deep venous thrombosis that developed after a
long international flight and that is currently being treated with an oral
anticoagulant. Denies history of UTIs, difficulty with urination, COPD,
renal stones, and immunosuppressive disorders.
• Surgical history: Wisdom tooth extraction as a teenager; no abdominal
surgical procedures.
• Medications: Lisinopril 10 mg daily, aspirin 81 mg daily, rosuvastatin
10 mg daily, rivaroxaban 20 mg daily, metformin 850 mg daily, and
niacin 1 g daily.
• Allergies: No known drug allergies.
• Family history: Mother and father have hypertension; sibling has
history of kidney stones.
• Social history: He denies current and previous tobacco use. He
works at a desk job and swims laps at his local pool several times a
week. All immunizations are up-to-date. He denies exposure to any
sick contacts. For the past 15 yr, he has had unprotected sex only
with his wife.
General appearance: Appears nontoxic but seems uncomfortable on
the exam bed.
Vital signs:
1. Temperature: 37° C
2. Pulse: 99 beats/min
3. BP: 150/90 mm Hg
4. Respirations: 16/min
5. Height: 6 ft (1.83 m)
6. Weight: 300 lb (136 kg)
7. BMI: 40.7
1. Skin: Warm and dry to the touch. No rash or lesions.
2. HEENT: Unremarkable
3. Pulmonary: Breath sounds present and equal bilaterally. No stridor, rales, or
wheezing.
4. Cardiovascular: Regular rate and rhythm; no murmurs or rubs. Radial and pedal
pulses present and equal bilaterally. No pedal edema.
5. Gastrointestinal: No ecchymoses. Bowel sounds normal in all quadrants.
Abdomen nondistended, soft, and nontender to light and deep palpation; no
guarding, rigidity, rebound, or masses. Negative Murphy sign. Rectal exam is
heme-negative.
6. Genitourinary: Circumcised penis, bilateral descended testes. Testes and
epididymal bodies nontender to palpation. No costovertebral angle tenderness.
7. Musculoskeletal: Muscle strength is intact in all four limbs without any
tenderness to palpation or movement.
8. Neurologic: Unremarkable
9. Mental status: Alert and oriented to person, place, time, and event.
Radiological sign:
The CT scans show a 6-mm density
with similar appearance to bone and a
decompressed ureter that is past the
density and ureteral dilation proximally.
The possible differential diagnosis for this case scenario are:
1. Appendicitis
2. Bowel obstruction
3. Cholecystitis
4. Epididymitis
5. Gastroenteritis
6. Ischemic colitis
7. Nephrolithiasis
8. Pancreatitis
9. Splenic laceration or contusion
10. Urinary tract infection (UTI)
11. Colon cancer
12. Dissecting aortic aneurysm
13. Diverticulitis
DIAGNOSIS:
Ureteral lithiasis
• The imaging findings, along with the presence of hematuria and
the colicky nature of the pain, suggest a kidney stone is causing
this patient's symptoms.
