Ddx of conditions Flashcards
Abdominal pain, relieved by leaning forwards or drinking alcohol. Weight loss. Anorexia. avoidance of food. DM (30 - 70%). Diarrhoea. Steatorrhoea (when 90% of exocrine tissue destroyed). Exudate production from lungs. Symptoms of other alcohol and smoking related illnesses. Mostly affects middle aged alchoholic men. Toxic(T): Alcohol (80% of western cases), tobacco, hypercalcaemia, chronic renal failure. (I)diopathic. (G)enetic, cystic fibrosis. (A)utoimmune. (R)ecurrent acute pancreatitis. (O)bstructive: neoplasia, pancreas divisum. NOT GALLSTONES.
Chronic pancreatitis
Acute abdominal or lumbopelvic pain - onset in minutes. General malaise and leg weakness. Possible vascular claudication.
Ruptured abdominal aortic aneurysm
Acute abdominal pain and possible lumbopelvic pain, that increases after menstruation in sexually active female. Fever, chills, dyspareunia (pain during intercourse) and abnormal vaginal discharge.
Pelvic inflamatory disease possibly related to STD (Chlamydia, gonorrhoea)
Acute abdominal pain between periods (while ovlating)
Mitelschmertz
Acute abdominal pain in sexually active woman with missed or spotty last period 6-8 weeks before. Sudden onset.
Ectopic pregnancy
Acute abdominal pain. Sudden onset. Young person. Poorly localised becoming more specific to RLQ within 2-12 hours. Nausea and vomiting. Annorexia, diahrroea.
Appendicitis
Age 30 to 60 most common. Head and neck pain. Worse with extension, lat flex or rotation. Better with flexion. Hand numbness, hoarseness, vertigo, tinnitus, deafness. Spastic gait. Drop attacks. ataxia. Loss of hand function. Poss loss of bl & bwl function. Cogwheel hyperreflexia.
Cervical stenosis/Cervical myelopathy
Age 30-50 yrs. Men > Women. Following twisting event. Severe LBP and then leg pain to below knee. Patient leans away from medial lesion or towards lateral lesion. May be LMN symptoms at site of lesion and possible UMN below lesion if posterior.
Prolapsed intervertabral disc with radiculopathy (lumbar)
Age 50+ History of breast, prostate, lung or kidney cancer. Gradual onset of pain, worse at night. Weight loss. Fatigue.
Spinal tumour (Mets)
Age 50+ Persistant LBP. Worse at night. Osteoporosis. Hypercalcaemia. Anaemia. Renal disease. Infection due to suppressed immune system.
Multiple myeloma
Alteration in mental state and cognitive function.Confusion. Slurred speech, Change in personality. Violent behaviour. Sleepy. Difficult to arouse. Flapping termors. Leads to coma - initially responsive to noxious stimuli, later unresponsive. Patient with liver disease.
Hepatic encephalopathy
Areas of skin that are itchy, dry, cracked, sore and red. Episodic. Most common on hands, backs of elbows, knees and face. Scratching makes it worse and can disrupt sleep. Area can turn temporarily darker or lighter after condition improves
Eczema
Asymptomatic at first. Upper abdominal pain radiating to the lower back. Asymptomatic at first. Jaundice, loss of appetite, Cachexia, Depression, Vomiting from duodenal obstruction, Lymphadenopathy, scratch marks (Obstructive jaundice), venous thrombosis. Affects 1 in 1000 over 70s. Men> women 2:1. Risk factors: age, smoking, acute pancreatitis. DM. Obesity. Diet rich in red meat and lacking fruit and veg. 5 to 10 % patients have genetic predisposition.
Pancreatic cancer (carcinoma)
Back or leg pain with varicous veins or history of DVT. Swelling in lower legs. Tiredness. Leathery, flaking or itching skin or ulcers on legs or feet. More likely in older obese inactive or pregnant women.
Venous hypertension
Back pain with balance and sensory problems.
Dorsal column lesion.
Bilateral calf pain - cramping aching. Does not depend on spinal position. Agrivated by physical exertion. Pain relieved promptly by rest. Sensory loss in stocking distribution. Cool, dry, scaly skin. Poor nail and hair growth. Decreased or absent pulses. 40-60+ yrs.
Vascular claudication
Bilateral or unilateral pain in low back, buttocks, thigh, calves, feet. Sciatic distribution. Pain increases with extension or walking, decreases with flexion, rest and sitting. Burning pain and numbness. Segmental sensory loss. Normal pulses. Good skin nutriton. 40-60+ yrs.
Neurogenic claudication
Bone pain in spine, pelvis, skull, shoulders, arms or legs. Most likely more than one bone. Can also cause joint pain, joint stiffness or compression or damage to nerves. Hearing loss, vertigo, headaches and tinnitus if in skull.
Paget’s disease
Breathlessness, tight chest, fast breathing, frequent sighing, tingling fingers, arms, mouth, muscle stiffness, trembling hands, dizziness, blurred vision, faintness, headaches, palpitations, tachycardia, cold hands and feet, shivering. Warm feeling in head, sickness, abdominal pain, tension, anxiety, fatigue, insomnia. History of stress.
Hyperventilation syndrome
Bronchiectasis. Spontaneous pneumothorax. Haemoptysis. Nasal polyps. Respiratory failure. Cor pulmonale. Lobar collapse. Malabsorbtion. Steatorrhoea. Intestinal obstruction. Billiary cirrhosis and portal hypertention. Gallstones. Diabetes. Delayed puberty. Infertility in men. Stress incontinence. Psychosocial problems. Osteoporosis. Arthropathy. Cutaneous vasculitis. The most common fatal genetic disease in caucasians. Autosomal recessive. 1:25 are carriers. Incidence 1:2500 live births. Diagnosed in childhood.
Cystic fibrosis
Calf pain and tenderness. Low grade fever. Pitting oedema around ankle. Patient may have risk factors: immobility, injury to vein or increased clotting.
DVT
Can be asymptomatic at first until it presents with signs and symptoms of renal failure. Uraemia. Hypertension. Oedema, fluid retention. Protienuria. Anaemia. Nocturia can be an early symptom. Tiredness, breathlessness. At end stage: Pruritis, anorexia, nausea, vomiting, hiccups, twitching, fits, drowsiness and coma. Hypertensive encephalopathy. 10% of adults in developed nations have mild CKD. Causes: Congenital genetic. Renal artery stenosis. Hypertention. Glomerular disease (IgA nephropathy). Interstitial disease. Systemic inflammatory disease (SLE, vasculitis). DM. Unkown causes. Immunological injury (immune reaction triggered by streptococcus), inherited abnormality.
Chronic kidney disease (CKD)/ Glomerolunephritis
Can be asymptomatic. Dyspnoea and decreased lung function. Gland enlargement. Skin plaques and nodules. Bone cysts on fingers. Space occupying lesion in brain. Diabetes insipidus. Uveitis. Liver disease. Risk factors: Colder parts of northern europe. > west indian or asians, but eskimos, arabs and chinese rarely affected. Presents in spring and summer. Genetic link - family clustering. Less frequent in smokers.
Sarcoidosis
Can be asymptomatic. Headache with progressive or constant neurological signs and symptoms. Vomiting. Fits. Changes to vision. History of cancer. Wakes with headache in morning.
Brain tumour
Can be asymptomatic. Highly variable. Weakness, fatigue, muscle cramps, weight loss, anorexia, nausea, vomiting, upper abdominal discomfort. Hepatic insufficiency (jaundice, circualory changes, endocrine changes (menstrual, impotence etc.) heamorragic tendancy. Hepatic encephalopathy. Digital clubbing. Dupuytrens contracture. Can also lead to shortness of breath, hepatopulmonary syndrome, hypoalbuminaemia. Any age. Important cause of premature death and morbidity. Most common causes: Chronic viral hepatitis. Prolonged excessive alcohol consumption. Other causes: Non alcoholic fatty liver disease. Autoimmune (PSC & PBC). Secondary biliary (obstruction) or cystic fibrosis. Genetic (haemochromatosis (iron), Wilsons disease (copper), antitrypsin deficiency). Unknown cause. Chronic venous outflow obstruction
Cirrhosis of the liver
Can be asymptomatic. Recurrent pain in right upper & central abdomen, right shoulder tip,neck scapula and thoracic spine (bilary colic), often at night or after a heavy or fatty meal. Possible nausea and vomiting. Pain not relieved by vomiting. Symptoms of acute cholecystitis but milder. Fat, fair, female, fertile, forty.
Cholelithiasis/chronic cholecystitis
Can be asymptomatic. Sudden onset frequency of micturition. Urgency. Dysuria (scalding pain in urethra during micturition). Suprapubic pain during and after voiding. Constant dull pain in pubic region. Back pain. Strangury (intense desire to pass more urine after micturition). Cloudy, unpleaseant smelling urine. Microscopic or visible haematuria. General sense of unwellness. Can lead to septicaemia. Very common. Women > men. Less common in children. Risk factors: Incomplete emptying from obstruction - kidney stones, neurological problems, uterine prolapse, vesico-ureteric reflux. Catheter or stent. Post menopausal vaginitis, or urethritis. DM. Chemotherapy, HIV. Extra risk for women: sexually active, use of diaphram or spermicide. Extra risk for men: enlarged prostrate.
Urinary tract infection (Lower UTI)
Cardiac pain (dull heavy, squeezing, crushing burning) in centre of chest, neck, jaw, arms, possibly back, without exertion. Dyspnoea. Orthopnoea. Discomfort rather than pain. Takes several minutes or longer to develop. Sweating, nausea, vomiting. Collapse/syncope. Pallor. Nitroglycerin does not help. Onset can be sudden or gradual. Women more likely to get non pain symptoms. Most likley caused by blod clot due to atherosclerosis, but can be other reasons.
Myocardial Infaction (MI) - Heart attack
Caused by head injury and can cause death if not treated promptly. Can be weeks or months after injury. Symptoms fluctuate. Headache, drowsiness, sensory loss, hemiparesis, epilepsy followed by stupor and coma, but can resolve spntaneously.
Haemorrage - Subdural and extradural
Chest pain in patient with history of arthritis (osteophytes) or diabetes. Sharp stabbing pain, numbness and tingling. Bilateral. Can radiate to back. May also have abdominal pain, fever and pain in arms and shoulders.
Osteophitic Intercostal neuritis
Chest pain or dyscomfort similar to MI. Sudden severe persistant dyspnoea. Patient looks anxious. Signs of DVT - ankle oedema, calf tenderness. Smaller embolysm can cause heamoptysis and pleural chest pain. Causes: DVT. Inactivity. Blood vessel damage due to chemotherapy and vasculitis. Blood that clots too easily - Cancer, chemotharapy, radiotherapy, heart failure, thrombophillia, Hughes syndrome. Risk factors: Age > 60. Familial. Obese. Pregnant. Smoker. Combined pill or HRT.
Pulmonary embolism
Chest pain with popping or clunking with certain activities.
Slipped rib
Chronic bronchitis: Cough and sputum on most days for > 3 months in 2 consec year. COPD: impaired nutrition, weight loss, muscle weakness. Smoker’s cough (with black particles). Haemoptysis. Breathlessness. Morning headaches. Pink puffers: Thin and breathless. Blue bloaters: Oedema, hypercapnia, polycythaemia. Peripheral oedema. Pitting oedema. COPD is chronic bronchitis and emphysema. >40 yrs. Causes: Tobacco, biomass fuels (dev countries). Unsusual to develop COPD if smoked less than 10 pack years. Other risk factors: Occupation (coal, cadmium), Air pollution, Low birth weight, maternal smoking (lung growth), Infections, low socioeconomic status, nutrition, cannabis, genetic factors, airway hyperreactivity.
Chronic obstructive pulmonary disease (COPD)
Chronic productive cough, worse in mornings. Copious puulent sputum and halitosis. Fever, malaise, recurrent infection of lungs and pleura. Recurrent haemoptysis. May be the only symptom in “dry bronchiectasis”. Weight loss, anorexia, lassitude, digital clubbing, failure to thrive in children. Can be congenital: cystic fibrosis, ciliary dysfunction syndromes, primary hypogammaglobulinaemia. Aquired in children: Pneumonia (from whooping cough or measles). Primary TB. Inhaled foreign body. Aquired in adults: Suppurative pneumonia. Pulmonary TB. Allergic bronchopulmonary aspergillosis (asthmatic allergy to mould). Bronchial tumour.
Bronchiectasis
Chronic recurrent abdominal and possible lumbopelvic pain related to menstrual cycle with recent increase in pain. May pass blood in stool or rarely cough it up. Heavy or painful periods. Fertility problems. Depression. Pain during and after sex. Bleeding between periods. Exhastion and tiredness. Risk faactors: IUD use or post abortion. Genetic. Afro caribean, Asian.
Endometriosis
Chronic recurrent abdominal pain in lower abdomen, pelvis and possibly inner thighs, related to menstrual cycle.
Primary dysmenorrhoea
Chronic recurrent abdonimal pain with jaundice. Episodic tiredness, anorexia, nausea, diziness, IBS, concentration problems, general malaise. Triggered by dehydration, fasting, stess, illness, exertion, lack of sleep, surgery, menstruation. Genetic condition
Gilberts syndrome
Chronic thoracic pain or neck pain and stiffness with imbalanced muscle tighness and history of bad posture.
Postural syndrome
Colicky abdominal pain associated with defacation. Abdominal distention.Alternating constipation and diarrhoea. Rectal mucus. Feeling of incomplete defacation. Young women > men. Most common cause of GIT referral. Cause of absence from work and impaired quality of life. Stress worsens symptoms.
Irritable bowel syndrome
Colicky lower adbominal pain. Rectal bleeding. Peritonitis. Localised abcess. Fistula formation. Aneamia. Weight loss. Palpable mass. Hepatomegaly from metastases. Left colon: Early bleeding and obtruction. Right colon: Amemia, altered bowel habit. Obstruction late. Rectum: Early bleeding, mucus discharge, feeling of incomplete emptying. Common in the west, > 50s, genetic predisposition and dietary factors - red meat and saturated fat, some(5%) have single gene mutation as the cause, IBD with PSC, uterosigmoidostomy, acromegaly, pelvic radiotherapy. Obesity. Smoking. Cholesistectomy. Type 2 diabetes. Reduced risk: Asprin, NSAIDS, statins.Fibre, fruit and veg, calcium, folic acid and omega 3.
Colorectal cancer
Colicky pain in right lower abdomen, releived by defacation. Diarrhoea. Variable symptoms anywhere in GIT. Oral ulcers. Growth retardation. Sacroiliitis. Fistulous communication with bowel, skin, urinary bladder. General symptoms for IBD: Nausea. Vomiting. Weight loss. Relapse and remittance over years. Conjunctivitis, Iritis, Episcleritis. Mesenteric or portal vein thrombosis. Venous thrombosis. Arthralgia of large joints. Erythema nodosum. Pyoderma gangrenosum. Autoimmune hepititis. gall stones. Metabolic bone disease. Amyloidosis and oxylate caculi. Risk factors: Smokers. Ashkenazi jews. SLE. IBD patients with HLA B27 gene comonly develop AS.
IBD - crohn’s disease
Common cause of neck pain. More common over 45, even more over 60. Sharp burning arm pain in dermatome distribution. One side only. Gradual onset. Agf: looking behind. All: neck flexion or hands on head.
Cervical spondylosis with radiculopathy
Commonly caused by RTC. Can be caused by posture. - sitting for long periods , driving, desk job. Intermittent, dull achy pain in neck, upper back, shoulders and base of skull. Headache.
Cervical facet syndrome
Constant dizziness. Acute onset. Slowly improves. May have some associated hearing loss or tinnitus. Can be caused by stress, head injury, virus or bacteria. May have had a cold just before.
Labrithitis
Cough. Haemoptysis. Bronchial obstruction. Stridor. Chest pain. Nerve entrapment (Horner’s syndrome due to sympathetic nerves - ptosis, enopthalmos, miosis, hypohidrosis of face or pancoasts syndrome die to brachial plexus - pain in shoulder and inner arm, atrophy in hand). Dyspnoea. Dysphagia from mediastinal spread. Arrythmia or pericardial effusion from pericardium invasion. Swelling of neck, face, conjuntival oedema, headache from Superior Vena cava obstruction. Vocal cord parallysis or bovine cough if laryngeal nerve is affected. Mets can cause anorexia, weight loss, finger clubbing, liver , bone and neurological symptoms. Hormones can also be secreted from the tumour - SIADH (small cell - anti diuretics), andrenocorticotropic hormones (small cell) or hyper calcaemia (squamous). Men> women. 18% of all cancer deaths. Increasing in women. Causes and risk factors: Smoking. Passive smoking. Pollution. Ocupation - industrial materials ( e.g. silica, asbestos).
Primary Lung Tumours
Diffuse aching pain in cervical, thoracic, lumber spine or limb. Sudden high temperature and malaise. Swelling, redness, warmth, tender to touch. Lymph glands swollen. May be history of trauma, DM,RA or sickle cell.
Osteomyelitis
Diffuse headache with dry mouth and feeling of thirst. Lightheadedness. Dark coloured strong smelling urine. Passing urine less often. Tiredness.
Dehydration headache
Diffuse joint and bone pain, especially spine, pelvis and legs. Muscle weakness. Easy fracturing. Risk for elderly, housebound or nursing home or other lack of sunlight.
Osteomalacia/Rickets
Diffuse pain in right upper & central abdomen, right shoulder tip,neck scapula and thoracic spine (bilary colic). Pain severe and prolonged up to several hours after a fatty meal or at night after a drink. Possible nausea and vomiting. Pain not relieved by vomiting. Fever. Jaundice in only 10% of case. Mostly caused by cholelithiasis, but can be due to sickle cell, parasites, tumour or endocopic stent insertion.
Acute cholecystitis/Cholelithiasis
Difuse acute abdominal pain in RLQ suddenly relieved, followed by increase in pain. Rigid abdomen. > Young person. Nausea and vomiting. Shortness of breath.
Ruptured appendix/ Peritonitis
Dizziness or vertigo, tinnitus or tremors with or without hyperventialation. History of stress or emotional trauma.
Anxiety
Dull aching limb pain, swelling and local tenderness with history of trauma or overuse.
Muscle strain (limb)
Dull, deep and boring, diffuse pain in pubic area, coccyx and inner thighs or central lower abdomen. Hypersensitive to touch.
Referred viceral pain - Urinary bladder
Dull, deep and boring, diffuse pain in central lower abdomen. Hypersensitive to touch.
Referred viceral pain - Colon
Dull, deep and boring, diffuse pain in central mid thoracics or sternum. Hypersensitive to touch.
Referred viceral pain - Stomach
Dull, deep and boring, diffuse pain in central upper thoracics or left arm. Hypersensitive to touch.
Referred viceral pain - Heart (Angina, MI)
Dull, deep and boring, diffuse pain in left front and back of neck. Hypersensitive to touch.
Referred viceral pain - Lung or diaphram
Dull, deep and boring, diffuse pain in right lower anterior ribs, Hypersensitive to touch.
Referred viceral pain - Gall bladder
Dull, deep and boring, diffuse pain in right neck, shoulder and scapula or right posterior ribs. Hypersensitive to touch.
Referred viceral pain - Liver or gall bladder
Dull, deep and boring, diffuse pain in waist, abdominal and pelvic area. Hypersensitive to touch.
Referred viceral pain - Kidneys
Dull, deep and boring, diffuse pain umbilical area. Hypersensitive to touch.
Referred viceral pain - Small intestine or ovaries
Dyspepsia - more discomfort than pain, Anorexia, Nausia, Vomiting, Haematemesis and Melaena. H Pylori is most common cause.
Gastritis
Dyspnea - orthopnoea, extremely tired, agitated, pale, clammy, pulse rapid, cool peripheries. Left - more respiratory symptoms - rapid shallow respiration. Wheeze. Unable to speak. Can cause renal failure, hypo or hyperkalaemia, hyponatraemia, thromboembolism, arrhythmia, impaired liver function. Most common cause of premature death.
Heart failure (dilated cardiomyopathy) - acute
Dyspnoea at first with moderate exertion, gradually provoked by less exertion. Orthopnaea - use of pillows, waking in night. Cheyne-stokes respiration. Relapsing and remitting. Fatigue, listlessness, cold peripheries. Swollen ankles. Weight loss. R - Hepatomegaly, ascties and peripheral oedema. L - Pitting oedema, pulmonary oedema & pleural effusion.
Heart failure (dilated cardiomyopathy) - chronic
Effort related cardiac pain (dull heavy, squeezing, crushing burning in centre of chest, neck, jaw, arms, possibly back) similar to MI, but relieved by rest or nitroglycerin. Predicable. Long term. Dyspnoea. Also brought on by emotion, large meal or cold wind. Most likley caused by atherosclerosis in coronary artieries, but can be other reasons.
Stable angina
Episodic pain, swelling and stiffness in joints, especially hands, feet and wrists. Throbbing aching pain, worse in morning for > 1 hour. Joints red and tender to touch. Bilateral. Multiple joints. May also have tiredness, fever, sweating, anorexia, weight loss. can affect eyes, heart and lungs. Can cause joint deformities. Commonly starts age 40 to 50. More women than men. Genetic tendancy.
RA
Episodic recurrent severe vertigo lasting hours or days. Ear feels full. Tinnitus and hearing loss. Possible hypersensitivity to sound. Anxiety or depression. May be history of diabetes or fluid retention. Age 20 to 60. Familial tendancy.
Meniere’s disease
Extreme tiredness. Numbness and tingling. Blurring of vision. Problems with motility and balance. Muscle weakness and tightness. Unlikely to have all symptoms at once. Episodic. Unpredictable. Can lead to loss of vision in one eye, colour blindness, eye pain, light flashes when moving eye, double vision. Neuropathic pain - stabbing, burning with extreme sensitivity. Pain in muscles and joints. Ataxia. tremor. Dizziness. Vertigo. Cognitive dysfunction. Depression. Anxiety. Sexual problems. Frequency. Urgency. Nocturia. Constipation. Bowel and bladder Incontinence. Dysphagia. Dysphasia. Age 20 to 40 most common.
MS
First - Fatigue, lethargy, depression, iritability, anorexia, unintentional weight loss, frequency, thirst, salt craving, dehydration. Later - Nausea, vomiting, diarrhoea, joint or back pain. Muscle cramps. Reduced libido. Irregualr periods. Low blood sugar.
Adrenal disorders - Addison’s disease (hypoadrenalism)
Flu like symptoms. Respiratory chest pain. Lung consolidation and collapse. Obstructive emphysema. Pleural effusion. Meningitis. Pericarditis. Erythema nodosum. Phlyctenular conjunctivitis. Dactylitis. Pulmonary: Chronic cough with haemoptysis. Pyrexia. Pneumonia. Weight loss. Pneumothorax. Can have extra pulmonary symptoms. More common in developing countries. Risk from Smoking. HIV. Malignancy. DM type 1. Chronic renal failure. Silicosis. Malnutricion from GI disease. Vit A, D deficient. Recent measles.
Tuberculosis - primary
Frequent urination. Thirsty. Hungry. Can lead to CV disease, Kidney failure, foot ulcers and eye damage. Blurry vision, headache, fatigue, slow healing, itchy skin, rashes. Diabetic neuropathy. Risk factors: obesity, smoking.
Diabetes mellitis
Frozen shoulder. Causes unknown but associated with trauma, immobilisation, diabetes (poor blood flow), thyroid issues and cardiac problems. More common in women. Usually non dominant side. Severe pain during freezing phase. Tender to touch. May disturb sleep. Agf: ext rotation. Lying on it. Alf: Arm in sling position. Pain lessens during frozen phase.
Frozen shoulder/Adhesive capsulitis
Genetic condition. Inabilty to clot. Bruising. Joint pain and stiffness. Hot swollen tender joints..
Haemophillia
Genetic suseptability. More common in northern europe. 1% prevalence in UK. Can present at any age, most common 30-50. Females > males. Linked to hyposplenism. 50% asymptomatic. Oral ulcers. Infants present with diarrhoea, malabsorbtion, failure to thrive. Older childen - delayed growth, puberty delay, mild abdominal distension, short stature in adulthood. Adults: Tiredness, weight loss, folate deficiency, iron deficiency anaemia, dyspepsia, bloating, undernutrition. Risk of osteoporosis.
Coeliac disease
Gradual onset diffuse aching pain. Fatigue, weight loss fever, anaemia and unexplained fractures. More likely in young people or osteochondroma in hips, shoulders or pelvis.
Primary bone tumour
Gradual onset, but constant symptoms. Hearing loss in one ear (may be sudden). Tinnitus. Vertigo. Facial numbness, tingling or pain. Possible headache, but rare. Ataxia. Can be realted to neurofibromatosis.
Acoustic neuroma
Haematemisis after violent retching or vomiting. Melaena (blood in stool). Oesophageal pain. Risk factors: Alcoholism, eating disorders, severe morning sickness in pregnancy. Possibly hiatus hernia and NSAID abuse. Mostly men over 60.
Mallory - Weiss syndrome