System PE ID findings Noninfectious mimics Diagnostic features
Right parasternal
or suprasternal
pulsation
- Mycotic or luetic
ascending aortic
aneurysm
l Noninfectious ascending
aortic aneurysm
l Tortuous carotid artery
l Dissecting aneurysm of the
ascending aorta
l Right-sided aortic arch
Fever, positive blood cultures
in mycotic aneurysm. RPR in
luetic aneurysm.
Echocardiography in other
diagnoses.
Pericardial friction
rub
- Acute viral or
bacterial
pericarditis
l Collagen vascular diseases
(esp. SLE)
l Postpericardiotomy/MI
syndrome
l Uremia
l Pericardial metastases
Clinical context for post-
pericardiotomy syndrome.
Serologic testing, BUN/
creatinine,
echocardiography.
Apical pan-systolic
murmur
- Mitral regurgitation
in acute rheumatic
fever - Mitral regurgitation
in bacterial
endocarditis
l Mitral regurgitation due to
other causes—mitral valve
prolapse, papillary muscle
dysfunction/rupture,
endocarditis, severe
LV dilation.
Jones criteria in ARF.
Echocardiography in other
diagnoses.
Apical diastolic
rumbling murmur
- Relative mitral
stenosis in acute
rheumatic fever
(Carey Coombs
murmur)
l Mitral stenosis—late effect
of rheumatic fever or
degenerative valvular disease
l Austin Flint murmur
Jones criteria in ARF.
Echocardiography in other
diagnoses.
Basilar diastolic
blowing murmur
(LSB)
- Aortic regurgitation
in endocarditis
l Aortic regurgitation due to
hypertension, rheumatic heart
disease, aortoannular ectasia,
aortic dissection
l Pulmonic insufficiency
Blood cultures and IE stigmata
for IE. Echocardiography for
other diagnoses.
Pan-systolic
murmur LLSB
- Tricuspid
regurgitation in
endocarditis - Tricuspid
regurgitation in
rheumatic fever
l Tricuspid regurgitation in
Ebstein anomaly, prolapse,
carcinoid, papillary muscle
dysfunction, connective
tissue disorders (Marfan),
RA, radiation injury
Blood cultures and IE stigmata
for IE. Jones criteria for ARF.
Echocardiography for other
diagnoses.
Jaundice 1. Viral hepatitides
(A, B, E, EBV,
CMV)
- Ascending
cholangitis - Sepsis-associated
cholestasis - Leptospirosis
- Malaria
- Hemorrhagic
fevers - Relapsing fever
l Alcoholic liver disease
l Biliary tract obstruction
(stone, tumor, stricture)
l Drug induced
l Hemolytic anemia
l Cancer (primary or metastatic
to liver)
l Hepatic vein thrombosis
l Ischemic hepatitis
Clinical context. Serologic
testing. Culture. Peripheral
smear (hemolytic anemia,
malaria). US for CBD
obstruction, tumors/hepatic
vein thrombosis.
Doughy abdomen 1. Tubercular
peritonitis
l Peritoneal metastases
l Recent significant weight loss
l Peritoneal mesothelioma
Imaging (CT, US). Peritoneal/
ascites culture or biopsy.
Right lower
quadrant
tenderness
- Acute salpingitis
with a tuboovarian
abscess - Bacterial ileocecitis
(Yersinia
enterocolitica,
Campylobacter
jejuni,Salmonella
enteritidis)
l Acute appendicitis
l Cecitis/typhlitis
l Regional enteritis
l Diverticulitis
l Epiploic appendagitis
l Impaction of a stone in the right
ureter
l Meckel’s diverticulitis
l Ovarian cyst
Stool culture, specific serology
in enteric infections. CT
scanning/US for
noninfectious etiologies.
58 Mishriki