Differential Diagnosis of Cough

PRECIPITATING AND
AGGRAVATING FACTORS

AMELIORATING
FACTORS

NATURE OF
PATIENT

NATURE
OF SYMPTOMS

ASSOCIATED
SYMPTOMS

Viral upper
respiratory
tract infections

Most common
cause of acute
cough in all
ages

Acute onset of
noisy cough (over
hours or days)
Cough worse at
night and may
persist for 7-10
days
Sputum thick and
yellowish but
minimal amount
produced

Fever
Runny nose
Sore throat
General aches
and pains

Pharynx injected or
pale, boggy, and
swollen
Coarse rhonchi

Mycoplasmal
bronchitis or
pneumonia

Common cause
of acute cough
in school-age
children
Frequent cause
of persistent
cough in adults

Long incubation
period (about 21
days)
Severe cough may
persist for1-4
months
Other symptoms
(e.g., fever) abate
within 10 days

Same as for
bacterial
pneumonia
but not
usually as
severe

Scattered rales
Signs of
pneumonia

Viral bronchitis

Recurrent
infections are
most common
cause of persistent cough
in children,
who are often
asthmatic

Cough may persist

for 7-10 days

Fever

CONDITION

PHYSICAL
FINDINGS

DIAGNOSTIC
STUDIES

Acute Cough

107

Continued

Chapter 9 Cough

Chest radiograph
Cold agglutinins
Complement
fixation

CONDITION

NATURE
OF SYMPTOMS

ASSOCIATED
SYMPTOMS

History of
allergy in
family

Minimally
productive
May be nocturnal
Recurrent cough
without dyspnea
May have seasonal
incidence

Sneezing
Conjunctivitis
Tearing
Itching of eyes
and roof of
mouth
Postnasal drip

Noisy cough
Incidence highest in
winter
Acute onset
Cough worse at
night

Fever, chills
Signs of acute
infection
Pharyngitis
Conjunctivitis
Otitis
Abdominal
pain
Headache
Pleuritic chest
pain

Bacterial
pneumonia

AMELIORATING
FACTORS

PHYSICAL
FINDINGS

DIAGNOSTIC
STUDIES

Antihistamines

Boggy, edematous
nasal mucosa

Stained sputum
smear for
eosinophils

Chronic
debilitating
conditions

Signs of
pneumonia

Chest
radiograph
Sputum and
blood cultures

Recumbency
Chronic sinusitis
Vasomotor
rhinitis
Allergic rhinitis
Nonallergic
rhinitis with
eosinophilia

Mucoid secretions in
posterior pharynx
Palpation, percussion, and transillumination of sinuses
reveal sinusitis
Mucosa of nose/
oropharynx:
cobblestone
appearance

Chronic or Recurrent Cough

Postnasal drip

May not be
aware of
condition

Frequent throat
clearing and
hawking
Cough worse in
morning

Chapter 9 Cough

Allergies

NATURE OF
PATIENT

PRECIPITATING AND
AGGRAVATING FACTORS

108

Differential Diagnosis of Cough contd

May have family

history of allergies, atopy, or
asthma

Recurrent cough
Minimally or not
productive (if productive, secretions
clear and mucoid)

Shortness of
breath

Chronic
obstructive
pulmonary
disease

Elderly patients

Chronic
bronchitis

Most common
cause of
chronic cough
in adults (especially smokers)

May be minimally
productive
Often worse in
morning

Congestive
heart failure

Elderly patients
present
differently
May have
only chronic,
unexplained
cough

Cough often
nocturnal

Dyspnea on
exertion
Paroxysmal
nocturnal
dyspnea

Gastroesophageal reflux

Usually adults

Irritative, nonproductive cough

Heartburn,
eructation

Exercise
May be worse
during
seasonal
allergies

Bilateral wheezing

Shortness of
breath

Pulmonary
function tests
Response to
isoproterenol
and methacholine

Lungs hyperresoPulmonary
nant to percussion function tests
Auscultation
reveals distant
breath sounds,
scattered rhonchi,
wheezes, or prolonged expiration
Scattered rhonchi

Recumbency
Exercise

Diuresis

Rales
Pitting edema
Tachycardia
Gallop

Chest
radiograph
Potent diuretic
for 2-3
days should
improve
symptoms
Ejection fraction

Recumbency
Ingestion of
chocolate,
caffeine, or
alcohol
Exercise

Antireflux
measures,
including
diet,
drugs,
and
elevating
head of
bed

Usually none

Upper gastrointestinal
radiograph
Esophagoscopy
Esophageal pH
monitoring

109

Smoking
cessation

Chapter 9 Cough

Asthma

Differential Diagnosis of Heartburn, Indigestion, and Dyspepsia

PRECIPITATING AND
AGGRAVATING
FACTORS

NATURE OF
SYMPTOMS

ASSOCIATED
SYMPTOMS

Reflux
esophagitis

Adults
More
common in
pregnant
women
in later
months

Severe heartburn
Water brash with
and without
recumbency
Recurrent pain
radiates to back
(40%), arms, or
neck (5%)

Chest pain
Dysphagia
Belching (from
aerophagia)
Cough
Asthma,
especially
nocturnal

Recumbency
Straining or lifting
Drinking alcoholic,
caffeinated,
or carbonated
beverages
Eating heavy meals or
fatty, spicy, or acidic
foods
Smoking
Pregnancy
Exercise

Raising head of
bed
Antacids,
proton-pump
inhibitors
Small, frequent,
low-fat meals
Avoidance of
tight garments

Gastritis

Especially
alcoholics

Abdominal pain
Vague
indigestion
Heartburn

Decreased
appetite
Sense of
fullness
Nausea and
vomiting

Alcohol
Meals
Drugs (aspirin,
NSAIDs, corticosteroids, antibiotics,
antiasthma agents)

Bile gastritis may

be relieved by
vomiting
Proton-pump
inhibitors

Active,
chronic
gastritis

Especially
older adults

Indigestion

CAUSE

Nonulcer
dyspepsia

Diffuse abdominal pain or

discomfort

Nocturnal pain
uncommon

AMELIORATING
FACTORS

PHYSICAL
FINDINGS

DIAGNOSTIC
STUDIES
Pain often relieved
by viscous
lidocaine
Esophagoscopy
Upper GI
radiograph
Esophageal pH
monitoring

Tenderness on
abdominal
palpation
or epigastric
percussion

Endoscopy
Upper GI
radiograph
Gastric biopsy

Gastric mucosal
biopsy
Urea breath test
Serologic test for
H. pylori

Pain not usually

relieved by
antacids
Occasional relief
of symptoms
after treatment
for H. pylori

Endoscopy

213

Bismuth compounds (PeptoBismol)

Proton-pump
inhibitors
Antimicrobials

Chapter 18 Heartburn, Indigestion, and Dyspepsia

NATURE OF
PATIENT

Continued

214

Differential Diagnosis of Heartburn, Indigestion, and Dyspepsiacontd

AMELIORATING
FACTORS

PHYSICAL
FINDINGS

DIAGNOSTIC
STUDIES

Significant
emotional
investment
Other anxiety
symptoms
Belching (from
aerophagia)

Social/environmental
stresses

Reduction in
stress

No signs of
systemic
disease

Study findings
normal

Vague feelings
of indigestion

Abdominal
bloating
Belching
Passing flatus

Increased ingestion of
flatulogenic foods
(e.g., bagels, legumes,
high-fiber foods)
GI stasis
Gut hypomotility
Bacterial change
Constipation
Lack of exercise

Belching
Passing flatus

Gas
entrapment
(hepatic
or splenic
flexure
syndrome)

Abdominal
discomfort
Pain often
referred to
chest

Chest pain

Bending over
Wearing tight
garments

Passing flatus

Flexion of
thigh on
abdomen
replicates
symptoms

Abdominal
radiograph shows
trapped gas in
hepatic or splenic
flexure

Gallbladder
disease

Vague abdominal
discomfort
Occasional
distention
Indigestion

Nausea
Pain in right
shoulder

Fatty foods

Pain and
tenderness
on palpation
in RUQ

Cholecystograms
Sonograms

CAUSE

NATURE OF
SYMPTOMS

ASSOCIATED
SYMPTOMS

Functional GI
disorder

Children and
adults

Distention
Awareness of
peristalsis and
gurgling
Intermittent
symptoms
Vague, nonspecific symptoms
No weight loss
Continuous pain

Excessive
intestinal
gas

Common in
elderly

GI, Gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; RUQ, right upper quadrant.

Chapter 18 Heartburn, Indigestion, and Dyspepsia

PRECIPITATING AND
AGGRAVATING
FACTORS

NATURE OF
PATIENT

76

Differential Diagnosis of Chest Pain

ASSOCIATED
SYMPTOMS

Adult

Achy, dull, tight,

severe, pressing
Not usually
sharp or
sticking
Substernal

Women are
more likely to
have atypical
symptoms such
as back pain,
nausea, and
fatigue

Variant angina Adult

(Prinzmetals
angina)

Achy, dull, tight,

severe, pressing
Not usually sharp
or sticking
Substernal

Gastroesophageal reflux
disease

Any age

Burning
Tightness
May be identical
to that of
angina

Esophageal
spasm

Especially
obese
adults

May be identical
in quality to
angina

Angina
pectoris

Water brash
Heartburn

AMELIORATING FACTORS

PHYSICAL
FINDINGS

DIAGNOSTIC
STUDIES

Exertion
Cold exposure
Emotional stress

Nitroglycerin
Rest
Valsalvas
maneuver

Sinus tachycardia,
bradycardia, 
or apical 
systolic bulge 
coincident 
with pain
Xanthomas
Signs of heart
failure

Exercise ECG
Coronary
arteriography
Radionuclide tests
Stress
echocardiography

Often occurs at
rest or at night

Nitroglycerin
Rest

ECG during attack

Coronary
arteriography

Overeating
Recumbency
(may awaken
from sleep)
Occasionally
precipitated by
exertion

Antacids
Proton pump
inhibitors

Esophagoscopy
Ambulatory
monitoring of
esophageal pH
Short course of
high-dose 
proton pump
inhibitors

Often induced
by ingestion of
alcohol or cold
liquids

Occasionally
relieved by
nitroglycerin

Esophageal
manometry

Chapter 6 Chest Pain

NATURE OF NATURE OF
PATIENT
PAIN

CONDITION

RECIPITATING
P
AND AGGRAVATING
FACTORS

Mitral valve
prolapse

Any age

Not usually
substernal
Often has
sticking quality
May last several
hours
Not typical of
angina

Palpitations
Arrhythmias
Often occurs at
rest
Syncope

Hypertrophic
cardiomy
opathy

Any age

Pain may be
similar to that
of angina

Dyspnea
Arrhythmias
Lightheadedness

Intercostal
myositis

Any age but May have

more comsticking quality
mon in children and
athletes

Pain may be
aggravated by
nitroglycerin

Severe coughing
May be sharp or
sticking
Duration only a
few seconds

Pulmonary
embolus

Usually
adult

Sharp, severe,
often pleuritic

Echocardiogram
Phonocardiogram

Beta blockers
Squatting

Murmur
intensified by
nitroglycerin
and Valsalvas
maneuver
Decreased by
squatting

Echocardiogram

Localized
tenderness on
palpation
No pleural friction
Splinting of
tender area

May be precipitated by
certain movements (e.g.,
neck exercises
and twisting)
Not related to
stress
Tachypnea
Hemoptysis

Deep vein
thrombosis
Tachypnea
Minimal cyanosis

Spiral CT
d-dimer assay
scan
V / Q
Pulmonary
angiography
Continued

77

Prolonged
immobilization
Oral contraceptives, especially
in smokers

Radiographs of
cervicodorsal
spine

Chapter 6 Chest Pain

Adult

Click/late systolic
murmur

May intensify
with inspiration

Costochondritis
Cervicodorsal
arthritis

Beta blockers
Recumbency

78

Differential Diagnosis of Chest Paincontd

NATURE OF NATURE OF
PATIENT
PAIN

Pneumonia

ASSOCIATED
SYMPTOMS

AMELIORATING FACTORS

Fever
Cough

Chest wall
syndrome

Adult
More
common in
athletes

Often sharp and

sticking
Fleeting

Pericarditis

Any age

Sharp or dull
Protracted
duration

Fever
Recent viral
infection

Myocardial
infarction

Adult

Severe
Crushing
Precordial
Protracted
duration

Sweating
Fatigue
Nausea

Gas
entrapment
syndrome

Any age
Often obese

Dull, achy

Flatulence

PHYSICAL
FINDINGS

DIAGNOSTIC
STUDIES

Egophony
Dullness on
percussion
May be
aggravated by
recumbency
and certain
positions

Local tenderness
on palpation
Crowing
rooster
maneuver may
precipitate pain
Pericardial
friction
Not
relieved by
nitroglycerin

Aggravated by
bending and
tight garments

Passage of
flatus
Nitroglycerin

ECG
Echocardiogram
CBC
Cardiac troponins
ECG
Serial CK-MB levels
Radionuclide
studies

Flexing thigh and

palpation of
colon may elicit
pain

Gas in hepatic or
splenic flexure on
radiographs

CBC, Complete blood count; CK-MB, creatine kinase, muscle-brain subunits (CK2, found primarily in cardiac muscle); CT, computed tomography; ECG, electrocardiogram;
ventilation/perfusion.
V / Q

Chapter 6 Chest Pain

CONDITION

RECIPITATING
P
AND AGGRAVATING
FACTORS

378

Differential Diagnosis of Urethral Discharge and Dysuria

NATURE OF
SYMPTOMS

Cystitis

Most common
in women
ages 15-34 yr

Dysuria (worse at
end of flow)
Urgency
Frequency
Internal
discomfort
Acute onset
of symptoms
with bacterial
infection

Hematuria
Nocturia
Fever

Meatal stenosis may

cause recurrent UTI
in children
Drugs (e.g., NSAIDs,
cyclophosphamide)

Interstitial
cystitis

Women ages
20-50 yr

Dysuria
Marked
frequency of
small volume of
urine

Nocturia
Bladder pain
Urgency

Some relief of pain

with voiding

Dysuria
Urgency
Frequency
Gradual onset 
of symptoms
over 2-7 days
Dysuria
External
burning

CAUSE

Female
urethral
syndrome

Vaginitis (see
Chapter 33)

Candidiasis
more
common
in diabetic
patients

Avoidance of
urinating
Warm baths

DIAGNOSTIC
STUDIES

Suprapubic
tenderness
on 
palpation or 
percussion
Fever

Urine culture
Cystoscopy
Test for
Chlamydia
Pyuria by
urinalysis or
leukocyte
esterase test

Tenderness of
bladder base

Urine culture:
sterile
Cystoscopy:
Hunners
ulcers

Suprapubic
pain

Suprapubic
pain
No fever

Minimal
pyuria
Urine culture
result usually
negative

Vaginal
itching

Vaginal
discharge
on pelvic
examination

KOH and
saline wet
mounts for
Candida and
Trichomonas
Test for
gonococci

Chapter 32 Urethral Discharge and Dysuria

PRECIPITATING
ASSOCIATED AND AGGRAVATING AMELIORATING PHYSICAL
SYMPTOMS
FACTORS
FACTORS
FINDINGS

NATURE OF
PATIENT

Common
cause of
dysuria and
urethral
discharge in
young girls

Dysuria
External
burning
Urethral
discharge
(minimal)

Prostatitis

Men older
than 50 yr

Dysuria
Frequency

Meatal
stenosis

Children

Dysuria
Recurrent
UTI symptoms

Most common
in men

Sexually
transmitted
Urethral
discharge is
moderate to
large, purulent,
mucoid, or
mucopurulent
and develops 
1-3 wk after
coitus with
infected partner
Dysuria (worse
at beginning of
urine flow)

Backache
Fever
Decreased or
intermittent
stream

Bubble baths
Vaginal sprays and
douches

Vaginitis

Abrupt change in
frequency of ejaculation (e.g., after a
vacation)

May be costovertebral
tenderness
Prostate
tender on
palpation
on rectal
examination

Examination
and culture
of prostatic
secretions

Sexual contact

Urethral
discharge is
spontaneous
or elicited
by penile
stripping

Nucleic acid
amplification test

Urethritis:
Gonorrheal

379

Continued

Chapter 32 Urethral Discharge and Dysuria

Chemical
vaginitis

380

NATURE
OFPATIENT

NATURE OF
SYMPTOMS

Nongonorrheal
(chlamydial
or trichomonal)

Most common
in men

Sexually
transmitted
Symptoms usually
minimal or
absent
Discharge (if
present) is
observed on
awakening, thin
and clear or
whitish
Dysuria (ranges in
severity)
Urgency
Frequency

Mechanical

Most common
in young
boys and
girls

Dysuria
Minimal urethral
discharge

CAUSE

PRECIPITATING
ASSOCIATED ANDAGGRAVATING AMELIORATING PHYSICAL
FACTORS
SYMPTOMS
FACTORS
FINDINGS
Meatal or
urethral
irritant

Multiple sexual
partners

Horseback or bike
riding
Masturbation
Foreign body

KOH, Potassium hydroxide; NSAIDs, nonsteroidal anti-inflammatory drugs; UTI, urinary tract infection.

Thin, scanty,
and whitish
Urethral
discharge
appears
on penile
stripping

DIAGNOSTIC
STUDIES
Nucleic acid
amplification test
RNA
probe for
Trichomonas

Chapter 32 Urethral Discharge and Dysuria

Differential Diagnosis of Urethral Discharge and Dysuriacontd