Murtagh's Diagnostic Strategies

Murtagh's Diagnostic Strategies
Abdominal pain in women
Probability diagnosis
Primary dysmenorrhoea
Mittelschmerz
Pelvic/abdominal adhesions
Endometriosis
Serious disorders not to be missed

Vascular:
• internal iliac claudication
Neoplasms including cancer
• ovary
• uterus
• other pelvic structures
Infection:
• PID
• pelvic abscess
• appendicitis
Other:
• ectopic pregnancy
Pitfalls (often missed)

Endometriosis/adenomyosis
Torsion of ovary or pedunculated fibroid
Constipation/faecal impaction
Pelvic congestion syndrome
Misplaced IUCD
Nerve entrapment
Referred pain (to pelvis):
• appendicitis
• cholecystitis
• diverticulitis
• UTI
Masquerades checklist
Depression
Drugs
Spinal dysfunction (referred pain)
UTI
Is the patient trying to tell me something?

Can be very relevant. Consider various problems and sexual dysfunction.
Key history
The pain should be linked with the menstrual history, coitus and the possibility of an early
pregnancy. For recurrent and chronic pain, it is advisable to instruct the patient to keep a diary
over two menstrual cycles. Risk factors in the past history should be assessed, for example:
• IUCD (salpingitis, ectopic pregnancy)

• infertility (endometriosis, salpingitis)
• tubal surgery (ectopic).
Key examination
Use the traditional abdominal and pelvic examination to identify the site of tenderness and
rebound tenderness, and any abdominal or pelvic masses. The pelvis should be examined by
speculum (preferably bivalve type) and bimanual palpation.
Proper assessment can be difficult if the patient cannot relax or overreacts, if there is
abdominal scarring or obesity, or if extreme tenderness is present. It is therefore important,
especially in the younger and apprehensive patient, to conduct a gentle, caring vaginal
examination with appropriate explanation and reassurance.
Key investigations
• FBE/ESR/CRP
• Urine MC
• Chlamydia PCR
• Cervical swabs MC
• Serum β-HCG
• Vaginal and/or pelvic ultrasound
• Laparoscopy if appropriate
Diagnostic tips
• Think of endometriosis and ovarian cysts in any woman with lower abdominal pain.
• Recurrent pain related to menstruation is typical of dysmenorrhoea or endometriosis.
• Ectopic pregnancy remains a potentially lethal condition so always be ‘ectopic minded’.
• A position β-HCG plus an empty uterus and an adnexal mass are the classic diagnostic
features of ectopic pregnancy.
Abdominal pain, acute in adults
Acute gastroenteritis
Acute appendicitis
Mittelschmerz/dysmenorrhoea
Irritable bowel syndrome
Biliary colic/renal colic
Peptic ulcer

Vascular:
• myocardial infarction (esp. inferior)

• splenic infarction
• ruptured AAA
• dissecting aneurysm aorta
• mesenteric artery occlusion
Cancer:
• of bowel with large or small bowel obstruction
Infection:
• acute cholecystitis
• acute salpingitis
• peritonitis/spontaneous bacterial peritonitis
• ascending cholangitis
• intra-abdominal abscess
Other:
• pancreatitis
• small bowel obstruction/strangulated hernia
• sigmoid volvulus
• perforated viscus (esp. perforated peptic ulcer)

Acute appendicitis (atypical)
Myofascial tear/muscle wall pain
Pulmonary causes:
• pneumonia
• pulmonary embolism
Faecal impaction (elderly)
Acute diverticulitis
Herpes zoster
Acute hepatitis
Inflammatory bowel disease
Rarities:
• porphyria
• lead poisoning
• haemochromatosis
• haemoglobinuria
• Addison disease
Depression
Diabetes (ketoacidosis)
Drugs (e.g. NSAIDS, iron tablets, narcotics, cytotoxics)
Anaemia (sickle cell)
Spinal dysfunction (referred)
UTI (inc. urosepsis)

May be very significant. Consider Munchausen syndrome, sexual dysfunction and abnormal
stress.
Key history
Pain has to be analysed according to the usual SOCRATES features. In respect to associated
symptoms and signs, special attention has to be paid to anorexia, nausea or vomiting, micturition,
bowel function, menstruation and drug intake.
Key examination
A useful checklist is:
• general appearance
• oral cavity
• vital parameters incl. temperature, pulse
• abdominal examination: inspection, auscultation, palpation and percussion (in that order)
• rectal examination
• inguinal region
• vaginal examination (if appropriate)
• urine analysis
Key investigations
• FBE
• ESR/CRP
• Serum lipase or amylase
• Urine MC
• LFTs
• H. pylori tests
• Faecal blood
Consider:
• imaging including plain X-ray, ultrasound, IVU, CT scan and others according to
suspected conditions
• upper GI endoscopy
Diagnostic tips
• Upper abdominal pain is caused by lesions of the upper GIT.
• Lower abdominal pain is caused by lesions of the lower GIT or pelvic organs.
• Early severe vomiting indicates a high obstruction of the GIT.
• Acute appendicitis features a characteristic ‘march’ of symptoms:
o pain → anorexia, nausea → vomiting.
Abdominal pain, acute in children
Infant ‘colic’ (2–16 weeks)
Gastroenteritis (all ages)
Mesenteric adenitis

Infection:
• acute appendicitis (mainly 5–15 years)

• pneumonia (esp. right lower lobe)
• pyelonephritis
• peritonitis
Cancer:
• colon cancer (rare)
Other:
• intussusception (peaks at 6–9 months)

• bowel obstruction
• coeliac disease
• strangulated inguinal hernia

Child abuse
Constipation
Torsion of testes
Lactose intolerance
Peptic ulcer
Infection: mumps, tonsillitis, pneumonia (esp. right lower lobe), EBM, UTI, hepatitis
Adnexal disorders in females (e.g. ovarian)
Rarities:
• Meckel diverticulitis
• Henoch–Schönlein purpura
• inflammatory bowel disease
• sickle crisis
• lead poisoning
Diabetes mellitus
Drugs
UTI
Psychogenic consideration
Important cause
Key history
Differentiate the severe problems demanding surgery from the non-surgical ones. About 1 in 15
will have a surgical cause for pain. The causes are often age specific so a family history is
important.
Key examination
• Note general appearance, vital signs and oral cavity
• Abdominal examination: inspection, auscultation, palpation and percussion (in that order)
• Rectal examination is mandatory: look for constipation including impacted faeces
• Examine lungs, especially if lower lobe pneumonia suspected
• Consider gentle abdominal palpation with a soft toy
Key investigations
• Rule out urinary infection with urinalysis. Blood, protein and leucocytes may all be
present with acute appendicitis. Nitrites are more specific for UTIs
• FBE/ESR/CRP
• Scanning according to findings
• Imaging (e.g. oxygen/barium enema) as appropriate
Diagnostic tips
• Consider mesenteric adenitis in a flushed febrile child with an URTI or tonsillitis.
• Vomiting occurs in at least 80% of children with appendicitis and diarrhoea in about
20%.
• A pale infant with severe colic and vomiting indicates acute intussusception.
Abdominal pain, chronic or recurrent in

adults
Mittelschmerz/dysmenorrhoea
Constipation
Peptic ulcer/gastritis

Vascular:
• mesenteric artery ischaemia

• AAA
Cancer/neoplasia:
• bowel/stomach cancer
• pancreatic cancer
• ovarian tumours
Infection:
• hepatitis
• recurrent PID

Adhesions
Appendicitis
Biliary disease: gallstones, sludge
Food allergies
Hernia
Lactase deficiency (i.e. lactose intolerance)
Chronic pancreatitis
Coeliac disease
Inflammatory bowel disease
Crohn disease
Endometriosis
Diverticular disease
Subacute obstruction (cancer, adhesions, etc.)
Rarities:
• tropical infections (e.g. hydatids, melioidosis, strongyloides)

• uraemia
• lead poisoning
• porphyria
• sickle cell anaemia
• hypercalcaemia
• Addison disease
Depression
Drugs
Spinal dysfunction
UTI
A strong possibility: consider hypochondriasis, anxiety, sexual dysfunction, Munchausen
syndrome.
Key history
This includes a detailed pain analysis, especially associated features such as micturition, bowel
function, menstruation, diet and psychological features. Note relevant past history (incl.
abdominal surgery), drug intake, travel, family history. Enquire about ‘red flags’ for organic
disease (e.g. weight loss, fever, nocturnal pain or diarrhoea, progressive symptoms).
Key examination
• General appearance including psyche and vital parameters
• Abdominal examination: inspection, auscultation, palpation, percussion (in that order)
• Rectal examination
• Vaginal examination (if appropriate)
• Office urine test
Key investigations
• Urinalysis including MCU
• FBE
• ESR/CRP
• Lipase/amylase
• LFTs
• U&E
• Plain abdominal X-ray
• Other imaging (e.g. ultrasound, IVU) according to findings and intuition
• Endoscopy as appropriate
Consider
• H. pylori testing
• coeliac disease
Diagnostic tips
• Consider gallstones and duodenal ulcer if the patient is woken (e.g. at 2–3 am) with
abdominal pain.
• Be very mindful of constipation, especially in the elderly, and be skilled at digital rectal
examination.
• Avoid repeated investigations unless a new symptom develops and the patient becomes
unwell.
Abdominal pain, recurrent in children

Non-organic recurrent abdominal pain (RAP)
Constipation
Recurrent viral illness (mesenteric adenitis)

Infection:
• recurrent urinary infection/ureteric reflux

• parasitic infection of gut (e.g. pinworm, strongyloides, whipworm)
• tuberculosis
Cancer:
• colon cancer (rare)
Other:
• hydronephrosis

Inflammatory bowel disease (IBD)
Childhood migraine equivalent (periodic syndrome)
Food allergy (incl. lactose intolerance)
Gastritis/oesophageal reflux
Rarities:
• Meckel’s diverticulum
• Temporal lobe epilepsy
• Sickle cell disease
o Henoch-Schönlein purpura
o irritable bowel syndrome (IBS)
Depression
Diabetes
Drugs
Spinal dysfunction
UTI

Highly likely as non-organic (functional) RAP is common. Consider anxiety and depression.
Key history
RAP, which is three distinct episodes of abdominal pain over 3 or more months, occurs in 10%
of school-aged children. In only 5–10% will an organic cause be found. A very careful history
includes the site, radiation, onset, duration and periodicity of the pain, and aggravating, relieving
and associated factors. Ask if the pain wakes the child at night, interferes with activities and is
associated with anorexia, vomiting, diarrhoea, dysuria or weight loss, or is related to food.
Family history of abdominal pain, migraine, IBD or IBS. Enquire about social history, school
difficulties, stressors and anxiety.
Key examination
• Usual systematic examination including rectal examination
• Growth chart is important
Key investigations
• Urine analysis and M&C
• FBE/ESR/CRP
• Plain abdominal X-ray to assess any faecal retention
• Ultrasound for suspected kidney tract or ovarian pathology
Diagnostic tips
• Avoid the trap of excessive investigations.
• In approximately 90% of RAP patients referred to hospital no underlying cause is found,
but take the problem seriously.
• Talk to the child alone, if possible.
• Organic disease is indicated by pain distant from the umbilicus and/or waking with pain
at night, associated with vomiting, loss of appetite or weight, change in bowel habit,
failure to thrive and inability to undertake normal activities.
Abdominal swelling (generalised)
Pregnancy
Obesity
Constipation, esp. chronic
Enlarged bladder
Fibroid uterus/ovarian tumour/cyst

Vascular:
• CCF (ascites)
• aortic aneurysm
Infection:
• intrabdominal abscess
• peritoneal tuberculosis
• hydatid cyst
• clostridial intra-abdominal infection
Cancer:
• ovary, stomach, colon, other

• carcinomatosis peritonei
Other:
• ascites (several causes)

• intestinal obstruction (large bowel)
• acute gastric dilatation
Hepatomegaly, splenomegaly
Hydronephrosis
Massive lymphadenopathy/lymphosarcoma
Rarities:
• chronic idiopathic pseudo-obstruction

Consider pseudocyesis.
Consider the classic five:
• fat
• flatus
• fluid
• faeces
• fetus
Key history
• Is the swelling intermittent, variable or progressive (the most serious)?
• Associated symptoms, especially gastrointestinal, menstrual (?pregnancy)
• Red flags, especially weight loss, fever, pain, lymph nodes
• History of alcoholism, hepatitis, kidney disease, heart disorder
• Past history of abdominal surgery, cancer
Key examination
• General appearance
• Vital signs
• Abdomen (inspection, palpation, auscultation, percussion)
• Rectal and vaginal examination
• Tests for ascites (if present)
• Dipstick of urine
Key investigations
• FBE and ESR/CRP
• Urinalysis
• U&E and LFTs
• Plain abdominal X-ray, ultrasound (best)
• Pregnancy test in females with amenorrhoea
• Specialised imaging according to findings, e.g. CT scan
Diagnostic tips
• Be alert for pregnancy in women of childbearing age, especially teenagers and
perimenopausal women.
• Be alert for constipation, especially in the elderly.
• Weight loss with abdominal swelling suggests malignancy.
Amenorrhoea
Pregnancy
Perimenopause/menopause
Constitutional delay of puberty
Breast feeding
Physiological e.g. excessive exercise, weight loss
Drugs esp. iatrogenic
Polycystic ovarian syndrome

Infection:
• Severe systemic illness

• Pelvic inflammatory disease
Cancer:
• Cellular—lymphoma, leukaemia, myeloma

• Pituitary tumours e.g. prolactinoma
• Ovarian tumours/cancer
Other:
• Brain injury

Imperforate hymen (haematocolpos)
Anorexia nervosa
Primary ovarian failure
Hyperprolactinaemia
Rarities:
• Congenital adrenal hyperplasia

• Genital malformations
• Gonadal dysgenesis
• Asherman’s syndrome
• Turner’s syndrome
Drugs e.g. OCP, cytotoxics, metoclopramide, antipsychotics, valproate
Anaemia
Thyroid/other endocrine: adrenal, pituitary disorders

Consider eating disorders, pseudocyesis
Key history
Take menstrual (if any) history i.e. primary or secondary amenorrhoea, including age of
thelarche, detailed menstrual history and associations. Ask about strenuous exercise activities.
Systems review to include endocrine/pituitary features, e.g. headache, galactorrhoea, visual

defects, weight changes, fatigue, voice changes, cold/heat intolerance, libido and other. Past
medical history including obstetric and gynaecological surgery.
Drug history esp. OCP, LARCs, other hormones, opioids and those mentioned above under
drugs as masquerades. Also document family, psychological and social history.
Key examination
General features:
• appearance of patient
• vital signs
• physical features incl. BMI, skin, body hair distribution, signs of virulisation (i.e. note
any secondary sex characteristics)
• brief neurological assessment incl. visual fields
• breast examination
• pelvic examination
Key investigations
First line:
• HCG/pregnancy test
• FBE
• U&E
• FSH/LH
• TFTs
• prolactin
Consider:
• testosterone
• oestradiol
• chromosomal analysis
• ultrasound e.g. ovary
• CT/MRI pituitary fossa
Diagnostic tips
Consider anorexia nervosa, heavy dieting, PCOS, delayed puberty, imperforate hymen,
pregnancy and drugs (iatrogenic and social).
Hypothalamic amenorrhoea is usually functional and caused by weight loss, psychological stress
or excessive exercise.
Consider a serious intracranial disorder if headache and visual disturbance.

Amnesia, total or partial
Severe anxiety/stress
Major depression esp. post ECT
Ageing/dementia
Head injury
Alcohol excess incl. Korsakoff syndrome
Iatrogenic e.g. ECT, cardiac bypass surgery

Vascular:
• Cerebral haemorrhage/subarachnoid
• Cerebral infarction esp. vertebrobasilar
Infection:
• Cerebral e.g. meningitis, abscess

• Viral encephalitis e.g. Herpes Simplex
• Syphilis
• HIV/AIDS
Tumor/cancer:
• Cerebral tumour
• Paraneoplasia
Other:
• Anoxia/hypoxia
• Hypothermia
• Electrolyte disturbance esp. hyponatraemia
• Dehydration
• Post-ictal state

Transient global amnesia
B 1 deficiency incl. alcohol abuse
Dissociative fugue states
Depersonalisation disorder
Rarities:
• Wernicke’s encephalopathy
• Carbon monoxide poisoning
Depression esp. major
Diabetes: hypoglycaemia
Drugs: various e.g. Cannabis, amphetamines (see list)
Anaemia
Thyroid/other endocrine: hypercalcaemia/hypothyroid?

Conversion reaction (hysterical fugue)
Psychogenic amnesia/malingering
Key history
A careful history is required recording the nature of memory loss incl. onset, duration,
fluctuation and associations. Interview family members and check for possible bizarre behaviour.
The key history should incl. past medical history including diabetes, hypertension,
cerebrovascular disease; drug history esp. alcohol, smoking or illicit drugs (cannabis,
amphetamines, opioids, solvent sniffing), lithium, barbiturates, benzodiazepines, anticonvulsants,
digoxin, OTC drugs, etc.; and psychiatric history, incl. severe anxiety, stress, depression, fugue
features, dissociation or personality disorder.
Key examination
• General features: appearance of patient incl. central cyanosis, hydration status, vital signs
• Psychiatric assessment and mental state examination
• Neurological examination
Key investigations
First line:
• urinalysis
• blood sugar
• pulse oximetry
• FBE & ESR
• LFTs (γGT)
• Others according to history and findings
Consider:
• blood gases
• TFTs
• syphilis serology
• CXR
• imaging: cerebral CTscan or MRI
Diagnostic tips
Consider memory loss as a presenting feature of severe stress, anxiety or depression (which can
present as pseudo dementia in the elderly).
Antisocial behaviour in adults
Functional: no medical or mental component
Drugs: alcohol, illicit (see list) or prescribed
Alcohol: acute or chronic
Antisocial personality disorder esp. cluster B
Affective (mood) disorders
Drug withdrawal incl. alcohol, hypnotics
Mental impairment

Vascular:
• Cerebrovascular disease including SAH

• Acute coronary syndromes
Infection:
• Encephalitis/meningitis
• HIV/AIDS
• Septicaemia
Tumours:
• Cerebral tumours
Other:
• Post ictal (epilepsy)

• Delirium
• Subdural haematoma
• Psychosis: schizophrenia, bipolar, paraphrenia
• Schizotypal personality disorder

Head injury
Fluid and electrolyte imbalance
Dementia esp. early
Rarities:
• Neurosyphilis
• Prion disease e.g. CJD
• Premenstrual dysphoria syndrome
Depression—major
Diabetes: hypoglycaemia
Drugs: iatrogenic/social–illicit
Thyroid/other endocrine: hyper/hypothyroid

Consider conversion disorder (hysterical fugue)
Malingering/fabrication
Severe anxiety/panic
Key history
• Nature of behaviour and precipitants, associations
• Psychiatric history: anxiety, OCD, depression, hypomania, personality traits, fugue
features
• Past, family and psychosocial history, developmental history, epilepsy, Parkinson
disease, family history
• Drug history: prescribed (see list), OTC, alcohol, social/illicit drugs (see list)
Key examination
This is limited.
• General features: appearance and behaviour of patient, vital signs

• General respiratory, neurological and cardiovascular examination
• Pulse oximetry
• Mental state examination
Key investigations
First line:
• urinalysis
• blood glucose
• FBE
• U&E
Consider:
• LFTs (γGT)
• ECG
• TFTs
• KFTs
• cerebral imaging
Diagnostic tips
Pay close attention to drug use esp. alcohol, caffeine, narcotics and amphetamines e.g. ‘ice’
Prescribed drugs: major and minor tranquilisers, anti-Parkinson, cardiogenic, corticosteroids.
Non-prescribed drugs: marijuana, LSD, opioids, amphetamines, ecstasy, cocaine, gamma

hydroxybutyrate (‘fantasy’), solvents e.g. petrol sniffing.
Cluster B antisocial personality disorders incl. histrionic, narcissistic and borderline.

Arm and hand pain (excluding fractures)
Dysfunction of the cervical spine (lower)
Disorders of the shoulder
Medial or lateral epicondylitis
Overuse tendonopathy of the wrist
Carpal tunnel syndrome
Osteoarthritis of the thumb and DIP joints

Cardiovascular:
• angina (referred)
• myocardial infarction
• axillary vein thrombosis
• arm claudication (left arm)
Infection:
• septic arthritis (shoulder/elbow)

• osteomyelitis
• infections of tendon sheath and fascial spaces of hand
• sporotrichosis (‘gardener’s arm’)
Neoplasia/cancer:
• Pancoast tumour
• bone tumours (rare)

Entrapment neuropathies (e.g. median nerve, ulnar nerve)
Pulled elbow (children)
Foreign body (e.g. elbow)
Rarities:
• polymyalgia rheumatica (for arm pain)

• complex regional pain syndrome I
• thoracic outlet syndrome
• erythromelalgia
• Kienböck disorder
Depression
Diabetes
Spinal dysfunction

Highly likely, especially with the so-called RSI syndromes.
Key history
Include an analysis of the pain and a history of trauma, particularly unaccustomed activity. In
children ask about pulling the child up by the arms or a fall on an outstretched arm. Ask for
relationship of pain to any sleep disturbance.
Key examination
Inspect the arm as a whole with both arms free of clothing and compare both sides. It may be
necessary to examine a variety of joints including the cervical spine, shoulder, elbow, wrist and
various joints of the hand.
Key investigations
• FBE
• ESR/CRP
• Consider ECG, nerve conduction studies, plain X-ray according to rule ‘if in doubt, X-ray
and compare both sides’, ultrasound for soft tissue injuries (e.g. tendonopathy)
Diagnostic tips
The working rule for arm pain causing sleep disturbance:
• thoracic outlet: patient cannot fall asleep

• carpal tunnel syndrome: wake in middle of night then settles
• cervical spondylosis: wakes patient with pain that persists.
Always keep regional pain syndrome in mind for persistent burning pain in hand following
injury, trivial or severe.
Arthralgia/arthritis in children
Juvenile idiopathic arthritis (incl. still disease and psoriasis)
Viral polyarthritis (e.g. parvovirus, rubella)
Growing pains (leg)
Irritable hip (transient synovitis)
Traumatic arthritis
Reactive arthritis (post-infective)

Vascular (haematological disorders):
• thalassaemia
• haemophilia
Infection:
• rheumatic fever
• septic arthritis
• osteomyelitis
• meningococcaemia
• tuberculosis
• HIV
Cancer:
• leukaemia
• lymphoma
• neuroblastoma
Other:
• juvenile rheumatoid arthritis

Hip disorders:
• Perthes disease
• slipped upper femoral epiphysis
Osteochondritis dissecans
Henoch-Schönlein purpura
Kawasaki syndrome
Rarities:
• scurvy
• rickets
• periodic fever syndrome
Drugs (e.g. penicillins, cotrimoxazole)
Spine: juvenile ankylosing spondylitis
Key history and features in childhood

Arthralgia (joint pain) is a common problem in childhood. The complaint demands respect
because of the many serious problems causing it. Arthritis may be part of an infectious disease
such as rheumatic fever, rubella, varicella, human parvovirus, influenza or other viral infection
and is seen with Henoch-Schönlein purpura. Actually viral polyarthritis is very common in
children. An FBE is helpful as it may show lymphopaenia, lymphocytosis or atypical
lymphocytes.
Diagnostic tips
• Acute onset monoarticular arthritis associated with fever is septic until proved otherwise.
• 5% of all children complain of recurrent limb pain, which often awakens them from their
sleep. A careful history and physical examination are essential and perhaps simple basic
investigations may be appropriate.
• Growing pains and post-activity musculoskeletal pain are relatively common.
Arthralgia/arthritis
Osteoarthritis
Viral polyarthritis (e.g. hepatitis, parvovirus)

Infection:
• rheumatic fever
• endocarditis
• tuberculosis
• brucellosis
• pyogenic (septic) arthritis: gonococcus, Staphylococcus, Kingella kingae
• HIV arthropathy
• dengue fever
Cancer:
• bronchogenic carcinoma
• leukaemia/lymphoma
• secondary malignancy
Other:
• rheumatoid arthritis (RA)

• connective tissue disorders: SLE, scleroderma, polymyositis and dermatomyositis, other

Spondyloarthropathies (e.g. psoriasis)
Fibromyalgia syndrome
Polymyalgia rheumatica
Crystal deposition:
• gout
• pyrophosphate (pseudogout)
Haemarthrosis
Dengue fever
Lyme disease
Ross River virus
Avascular necrosis
Rarities:
• other vasculitides (e.g. polyarteritis nodosa)

• sarcoidosis
• Whipple disease
• hyperparathyroidism
• familial Mediterranean fever
• amyloidosis
• pigmented villonodular synovitis
Depression
Diabetes (?arthropathy)
Drugs: uncommon but some implemented
Thyroid disorder
Spinal dysfunction (spondyloarthropathies)

Always a consideration with pain.
Psychogenic factors aggravate chronic arthritic conditions.

Key history
There is such a multitude of causes of arthralgia that a skilful history to cover many angles is
required. Note the pattern of joint involvement (monoarticular or polyarticular), immediate and
more recent history, family history and drug use.
Enquire whether the joint pain is acute or insidious and confined to specific joints or fleeting as
in rheumatic fever.
Key examination
A systematic examination of the affected joint or joints should look for signs of inflammation,
deformity, swelling and limitation of movement.
Searching for associated systemic disease such as connective tissue disorders and infection
demands examination of the chest, heart and abdomen.
Key investigations
• FBE
• EBR & CRP
• Uric acid
• Urine analysis
• Joint X-rays
• Synovial fluid analysis and culture
• RA factor
• Autoantibodies (ANA, dsDNA, ENA), anti-CCP antibody (for RA)
• Other tests according to findings of tests for infection (e.g. specific serology, blood
culture)
Diagnostic tips
• The commonest cause of arthritis is osteoarthritis (OA).
• Other causes of monoarthritis include crystal deposition disease, sepsis, trauma and
spondyloarthritis.
• The pain of inflammatory disease is worse at rest and improved by activity.
• There should be no systemic manifestations with OA.
• With polyarthritis (usually PIPs) and rash consider viral arthritis or a drug reaction.
Back pain, lower
Vertebral dysfunction especially facet joint and disc (mechanical pain)
Musculoligamentous strain/sprain
Spondylosis (degenerative OA)

Cardiovascular:
• ruptured aortic aneurysm

• retroperitoneal haemorrhage (anticoagulants)
Neoplasia/cancer:
• myeloma
• pancreas
• metastases (e.g. lung, breast, prostate)
Infection:
• vertebral osteomyelitis
• epidural/subdural abscess
• septic discitis
• tuberculosis
• pelvic abscess/PID
• pyelonephritis
Other:
• osteoporotic compression fracture

• cauda equina compression

Spondyloarthropathies:
• ankylosing spondylitis
• reactive arthritis
• psoriasis
• bowel inflammation
Sacroiliac dysfunction
Spondylolisthesis
Spinal canal stenosis
Claudication:
• vascular
• neurogenic
Paget disease
Prostatitis
Endometriosis
Depression
Spinal dysfunction
UTI

Quite likely. Consider lifestyle, stress, work problems, malingering, conversion reaction.
Key history
Routine analysis of pain (SOCRATES approach), especially intensity of pain and its relation to
rest and activity and also diurnal variation. Ask about pain on standing, sitting and walking with
types of claudication (if any).
Review family history, occupational history, drug history, psychosocial history and ask
questions about red flags that are alarm symptoms of serious disease.
Key examination
Follow the LOOK, FEEL, MOVE, MEASURE clinical approach with an emphasis on
palpation—central and lateral.
The movements with normal ranges are:
• extension 20°–30°
• forward flexion 75°–90°
• lateral flexion (left and right) 30°.
Perform a neurological and vascular examination of the lower limb/s with pain.
Key investigations
This should be conservative, especially in the absence of red flags. Basic screening is:
• FBE
• ESR/CRP
• urinalysis
• serum alkaline phosphatase
• PSA in males 50–75 years
• plain X-ray if chronic pain and red flags.
Reserve CT scan, MRI or radionuclide scan for suspected serious disease (malignancy and
infection).
Diagnostic tips
• Continuous pain (day and night) points to neoplasm (esp. malignancy) or infection.
• Pain (and stiffness) at rest, relief with activity indicates inflammation (e.g.
spondyloarthropathy).
• Pain provoked by activity with relief at rest indicates mechanical (vertebral) dysfunction.
• Pain in the periphery of the limb can be discogenic causing radicular pain or spinal cord
stenosis causing neurogenic claudication or vascular causing intermittent claudication.
Back pain, thoracic
Musculoligamentous strains (mainly postural)
Vertebral dysfunction

Cardiovascular:
• dissecting aneurysm
• pulmonary infarction
• epidural haematoma (blood-thinning agents)
Neoplasia/cancer:
• myeloma
• pancreas
• lung (with infiltration)
• metastatic disease (e.g. lung, breast)
Infection:
• epidural/subdural abscess
• infective discitis
• pleurisy
• infectious endocarditis
• osteomyelitis
• pyelonephritis
Other:
• pneumothorax
• osteoporosis
Angina
Gastrointestinal disorders
• oesophageal dysfunction
• peptic ulcer (penetrating)
• hepatobiliary
• pancreatic
Herpes zoster
Spondyloarthropathies
Costochondritis:
• Tietze syndrome
Notalgia parasthetica
Chronic infection:
• tuberculosis
• brucellosis
Depression
Spinal dysfunction
UTI

Yes, quite possible with many cases of back pain.
Key history
Take a history analysing pain characteristics to differentiate between chest pain due to vertebral
dysfunction (musculoskeletal strain) and that caused by myocardial ischaemia.
Also drug history, family history, occupational history and questions about red flags that point to
serious disease.
Key examination
The LOOK, FEEL, MOVE, MEASURE clinical approach applies to the thoracic spine. The
emphasis is on palpation-central and laterally.
The movements and their normal ranges are:
• extension 30°
• lateral flexion (right and left) 30°
• flexion 90°
• rotation (right and left) 60°.
Key investigations
Consider:
• FBE
• ESR/CRP
• alkaline phosphase
• A plain X-ray is the main investigation, which may exclude the basic skeletal
abnormalities and diseases such as osteoporosis and malignancy. If normal and disease is
suspected a radionucleide scan or MRI is advisable.
Diagnostic tips
• The commonest site of pain is the costovertebral articulations of the spine.
• Pain of the thoracic spine origin may be referred anywhere to the chest wall.
• The older patient should be regarded as having a cardiac cause until proved otherwise.
• Thoracic back pain is frequently associated with cervical lesions that refer to the upper
back.
• The thoracic spine is the commonest site in the vertebral column for metastatic disease.
Breast lumps in women
Fibrocystic disease (mammary dysplasia) (32%)
Fibroadenoma (23%)
Cancer (22%)
Cysts (10%)
Breast abscess/periareolar inflammation
Lactation cyst (galactocele)

Vascular:
• thrombophlebitis (Mondor disease)
Infection:
• mastitis/breast abscess
• tuberculosis
Cancer:
• carcinoma
• ductal carcinoma in situ
• Paget disease of the nipple
• sarcoma
• lymphoma
• mastitis carcinomatosa
Other:
• phyllodes tumour
Duct papilloma
Lipoma
Mammary duct ectasia
Fat necrosis/fibrosis

Consider anxiety or cancer phobia (esp. if family history) and possibility of a ‘pseudo lump’ (e.g.
part of normal or prominent chest wall anatomy). If doubtful re-examine after next period or
refer.
Key history
Family history of breast disease and past history including trauma, previous breast pain and
details about pregnancies (complications of lactation such as mastitis, nipple problems and milk
retention).
Note any nipple changes or discharge that may indicate carcinoma.
Key examination
• Careful examination of both breasts with inspection looking for any asymmetry, skin
discolouration, tethering, peau d’orange or visible veins.
• Examine the nipples for retraction or ulceration and variations in level.
• Examine lymph nodes in a sitting position with the patient’s hands on hips.
• Palpation using the pulps of the fingers should systematically cover the six areas of the
breast: the four quadrants, the axillary tail and the region deep to the nipple and areola.
Key investigations
• The basis of investigation of a new breast lump is the triple test, which is:
o clinical examination (above)
o imaging: mammography ± ultrasound
o working rule for imaging: <35 years ultrasound; >35 years mammogram +
ultrasound
o fine needle aspiration ± core biopsy
Diagnostic tips
• Mammary dysplasia, which is the most common breast lump, is a common cause of cysts
especially in the premenopausal phase.
• Over 75% of isolated breast lumps prove to be benign but clinical identification of a
malignant tumour can only definitely be made following aspiration biopsy or histological
examination of the tumour.
• A ‘dominant’ breast lump in an older woman should be regarded as malignant.
Breast pain (mastalgia)
Pregnancy
Cracked or inflamed nipple
Cyclical mastalgia:
• benign mammary dysplasia

Vascular:
• acute coronary insufficiency

• thrombophlebitis (Mondor disease)
Infection:
• mastitis
• breast abscess
Cancer:
• breast (uncommon presentation)

• mastitis carcinomatosa

Pregnancy
Chest wall pain (e.g. costochondritis)
Pectoralis muscle spasm
Referred pain, esp. thoracic spine
Bornholm disease (epidemic pleurodynia)

Herpes zoster
Mechanical:
• bra problems
• weight change
• trauma
Rarities:
• hyperprolactinaemia
• nerve entrapment
• mammary duct ectasia
• sclerosing adenosis
• ankylosing spondylitis
Depression
Drugs (e.g. OCP, HRT, marijuana)
Spinal dysfunction

Yes. Fear of malignancy. Consider psychogenic causes.
Key history
Relate the pain to the menstrual cycle and determine whether the patient is pregnant or not.
Key questions:
• Could you be pregnant?

• Is your period on time or overdue?
• Is the pain in both breasts or only one?
• Do you have pain before your periods (cyclical mastalgia) or all the time during your
cycle (non-cyclical mastalgia)?
• Do you have pain in your back or where your ribs join your chest bone?
Key examination
• Systematic breast palpation to check for soreness or lumps including regional lymph
nodes
• Underlying chest wall and thoracic spine (T3–T6)
Key investigations
• Pregnancy test
• Mammography (>40 years) and ultrasound
• FNA/excision biopsy for lump with localised pain
• Consider CXR and ECG
Diagnostic tips
• Consider cancer or candida if constant (prickling) breast pain.
• Consider a rare florid form of breast cancer, ‘mastitis carcinomatosa’, if red, hot area.
• Watch for abscess if a lactating woman has unilateral breast pain and ‘flu’ symptoms.
Breast, nipple discharge
Pregnancy
Physiological
Intraduct papilloma
Lactation/lactation cysts
Mammary dysplasia

Infection:
• acute mastitis/discharging breast abscess

• areolar abscess (infected gland of Montgomery)
• tuberculosis abscess
Cancer:
• intraduct carcinoma
• invasive carcinoma
• Paget disease of nipple
Other:

Mammary duct ectasia
Drugs (e.g. chlorpromazine, metoclopramide, OCP, cimetidine, opiates, amphetamines, CCBs,

tricyclic antidepressants, phenothiazine)
Rarities:
• mammary duct fistula
• mechanical stimulation
Drugs (as above)
Endocrine: hyperprolactinaemia, hypothyroidism
Key history
Family history of breast disease and past history including previous breast lumps, pain or nipple
discharge. Note association with pregnancy, postpartum and lactation. Investigate drug intake
including OTC preparations and illicit drugs especially opioids.
Key examination
• Careful examination of the breast, particularly the nipples and ductal area
• Examine associated lymph node regions
Key investigations
Select from:
• pregnancy test
• swab of any purulent discharge
• cytology of discharge
• prolactin level
• excision biopsy of discharging duct area.
Discuss imaging (e.g. mammography, ultrasound, galactography) with consultant
Diagnostic tips
• If the discharge is bilateral then serious breast disease is unlikely—consider mammary
dysplasia and pregnancy.
• Bloodstained discharge is caused by intraduct papilloma (commonest) and intraduct
carcinoma.
• Green-grey discharge: consider mammary dysplasia and mammary duct ectasia.
• Yellow discharge: intraduct carcinoma (serous), mammary dysplasia and pus from a
breast abscess.
• Milky-white discharge (galactorrhoea): lactation, lactation cysts, hyperprolactinaemia
and drugs.
• Consider malignancy in women with a new breast discharge (>40 years) and bloody
discharge.
• Nipple discharge in a male is always abnormal.
Calf pain
Simple muscular cramp
Muscle soreness (post exercise)
Muscle injury esp. gastrocnemius tear
Claudication esp. vascular (intermittent)

Vascular:
• Deep venous thrombosis

• Peripheral vascular disease
• Superficial thrombophlebitis
• Popliteal artery entrapment
Infection:
• Cellulitis
Other:
• Achilles tendon rupture

• Neurogenic claudication
• Deep posterior muscle compartment syndrome

Referred pain: knee, spine
Ruptured Baker’s cyst
Superficial posterior compartment syndrome
Nerve entrapment e.g. tibial, sural

Stress fracture of fibula
Rarities:
• Hypocalcaemia→cramps
• Motor neurone disease
Diabetes
Drugs e.g. beta blockers
Thyroid/other endocrine: hypocalcaemia
Spinal dysfunction: L5 referred

Possibly muscle tension
Key history
A history of the features of the pain-quality, onset (acute or slow), ‘tearing’ or ‘popping’ sound,
relation to activity and associations esp. back or knee pain.
Document any preceding sporting activity, travel, immobilisation, varicose veins or

claudication—neurogenic or vascular pattern.
Key examination
• Calf muscle examination incl. Achilles tendon, functional stress, swelling or bruising
• Lumbosacral spine and knee of affected side
• Veins and arteries of leg esp. peripheral pulses
• Neurological—sensation, power, reflexes esp. ankle
Investigations
Nil for most cases.
Consider:
• FBE
• ESR/CRP
• muscle enzymes
• imaging e.g. ultrasound, D-dimer, venography, angiography
Diagnostic tips
Neurogenic claudication is muscular pain starting proximal and radiating distal on walking, and
persists for a while after resting. Vascular claudication starts in the calf, radiates proximal and
abates on rest.
Chest pain in adults
Musculoskeletal (chest wall) incl. costochondritis
Psychogenic
Angina

Cardiovascular:
• myocardial infarction/unstable angina

• aortic dissection
• pulmonary embolism/infarction
Neoplasia/cancer:
• lung cancer
• tumours of spinal cord and meninges
Infection:
• pneumonia/pleuritis (pleurisy)
• mediastinitis
• pericarditis
• myocarditis
Pneumothorax

Mitral valve prolapse
Oesophageal spasm
Gastro-oesophageal reflux
Biliary colic
Peptic ulcer
Herpes zoster
Fractured rib (e.g. cough fracture)
Spinal dysfunction
Precordial catch (‘stitch’ in side)
Rarities:
• pancreatitis
• Bornholm disease (pleurodynia)
• cocaine inhalation (can ↑ ischaemia)
• hypertrophic cardiomyopathy
Depression (possible)
Anaemia (indirect)
Spinal dysfunction

Consider functional causes, especially anxiety with hyperventilation, opioid dependency.
Key history
This needs to be meticulous because of the life-threatening causes. Analyse the pain into its usual
characteristics with the SOCRATES system.
Note family history drug history, psychosocial history and past history, especially if
immunocompromised (e.g. diabetes or metabolic syndrome).
Key examination
• General appearance
• Vital signs
• Peripheral circulation
• Careful examination of cardiovascular and respiratory systems
• Upper abdominal palpation
Key investigations
• Base tests available to the GP are ECG, cardiac enzymes and CXR and in most instances
help confirm the diagnosis.
• Otherwise specialist investigations including imaging are confined to hospitals and
cardiology centres.
Diagnostic tips
• Consider chest pain as due to a coronary syndrome until proved otherwise.
• The history remains the most important clinical factor in the diagnosis of ischaemic heart
disease and other conditions.
• With angina a vital clue is the reproducibility of the symptom.
Chest pain in children
Musculoskeletal (chest wall pain):
• cough strain (10%)

• injury
• muscle strain
• costochondritis
• precordial catch syndrome (stitch in side)
• asthma
Note: Most cases are unknown (21%).

Vascular:
• ischaemic pain: structural cardiac conditions

• arrhythmias (e.g. PSVT)
Infection:
• pericarditis
• myocarditis
• pneumonia
• herpes zoster
Other:
• pneumothorax
• POTS syndrome

Kawasaki syndrome
Breast disorders
Rarities:
• Bornholm disease
• oesophagitis or gastric pain

Psychogenic: stress, anxiety, depression (10%).
Key history
• Usual features of the pain including aggravating and relieving factors such as movement,
exercise, rest, swallowing, breathing and eating.
• Note associated symptoms such as fever, cough, dizziness, overexertion, syncope and
recent viral illness.
• Note family history, especially cardiac disease including unexplained sudden death,
recent stressful events and drug history.
Key examination
• Vital signs especially pulse (including nature) and temperature
• Palpation of chest wall to determine any tenderness or signs of injury
• Basic cardiovascular and respiratory examination
Key investigations
• No investigation usually required
• Consider ECG and CXR
Diagnostic tips
• Most cases of chest pain in children are of unknown aetiology and probably psychogenic.
• Chest pain is more common in adolescents.
• Less than 5% of cases are caused by cardiac disease.
• Myocardial ischaemia is rare in children but consider it in any child with exercise-
induced pain, adolescents with longstanding diabetes and children with sickle cell
anaemia.
Chronic constipation
Simple constipation: low-fibre diet, poor fluid intake, lifestyle and bad habit
Slow transit (idiopathic) constipation
Normal transit (irritable bowel syndrome)

Intrinsic neoplasia: colon, rectum or anus, especially colon cancer
Extrinsic malignancy (e.g. lymphoma, ovary)
Hirschsprung (children)

Impacted faeces
Local anal lesions (e.g. anal fissure)
Drug/purgative abuse
Hypokalaemia
Depressive illness
Acquired megacolon
Diverticular disease
Rarities:
• lead poisoning
• hypercalcaemia
• dolichocolon (large colon)/megarectum
• Chagas disease
• systemic sclerosis
Depression
Diabetes (rarely)
Drugs (opiates, iron, others)—see list
Thyroid disorder (hypothyroidism)
Spinal dysfunction (severe only)

May be functional (e.g. depression, anorexia nervosa).
Key history
Define what exactly the patient means by constipation. The history should include stool
consistency, frequency, ease of evacuation, pain on defecation and the presence of blood or
mucus. A dietary and drug history is important.
Key examination
• The important aspects are abdominal palpation and rectal examination
• Test perianal sensation and the anal reflex
• Perform sigmoidoscopy
Key investigations
• Basic tests are FBE/ESR, occult blood in stool
• Consider serum calcium, potassium, CEA and TFTs
• If appropriate refer for sigmoidoscopy or colonoscopy and radiological studies (e.g. CT
colonography, bowel transit studies)
Diagnostic tips
• Alarm symptoms are rectal bleeding, recent constipation in those >40 years and family
history of cancer.
• Bleeding suggests cancer, haemorrhoids, diverticular disorder and inflammatory bowel
disease.
• Beware of hypokalaemia causing constipation in the elderly patient on diuretic treatment.
Drugs selected associated with constipation: analgesics, opioids esp. codeine, TCAs,
antacids esp. aluminium hydroxide, Ca channel blockers, SSRIs, cough mixtures, anti-
cholinergics, benzodiazepines.
Confusion, acute in adults
Hypoxia
Hypoglycaemia
Alcohol excess
Drug withdrawal incl. alcohol, hypnotics
Head injury

Vascular:
• Cerebral insufficiency incl. TIAs

• Acute coronary syndrome
• Cardiac arrhythmias
• Subdural or extradural haematoma
Infection:
• Any systemic infection esp. sepsis

• Cerebral e.g. meningitis, abscess
• HIV/AIDS
Tumor/cancer:
• Cerebral tumour
Other:
• Kidney failure
• Hepatic failure
• Respiratory failure e.g. COPD
• Electrolyte disturbance
• Dehydration
• Post-ictal state
• Psychosis

Iatrogenic-drugs incl. serotonin syn.
Hyperparathyroidism
Hypo/hyper-calcaemia
Sleep apnoea
Rarities:
• Fat embolism
• Prion disorders esp. CJS
• Vitamin deficiency e.g. B1 and B12
Depression
Diabetes: ketoacidosis, hypoglycaemia
Drugs (see list)
Thyroid/other endocrine—hyper/hypothyroid?
Urinary tract infection—nocturia

A consideration if nil findings.
Key history
A careful history is required incl. an interview with family members and witnesses.
Investigate the onset and circumstances of the behaviour, any possible bizarre behaviour. Past
medical history including diabetes, hypertension, cerebrovascular disease. Drug history esp.
alcohol or illicit drugs, prescription and OTC drugs.
Check thyroid status, esp. hyperthyroidism.
Key examination
• General features: appearance of patient incl. evidence of central cyanosis, hydration
status, vital signs incl. BMI
• Head and neck
• General respiratory and cardiovascular examination
• Possible source of infection
• Neurological examination
Key investigations
First line:
• urinalysis
• blood sugar
• pulse oximetry
• FBE
• ESR
• U&E
• calcium
Others according to history and findings
Consider:
• CXR
• ECG
• cardiac enzymes
• TFTs
• LFTs (γGT)
• CT scan
• CSF analysis
Diagnostic tips
Pay close attention to drug use, esp. alcohol, psychotrophics, narcotics, illicit agents,
anticholinergics, digoxin, corticosteroids, benzodiazepines esp. if desperate request for drugs.
Cough, chronic in children
Asthma
Recurrent viral bronchitis
Acute URTIs
Allergic rhinitis
Croup

Asthma
Cystic fibrosis
Inhaled foreign body
Tracheo-oesophageal fistula
Pneumonia
Chronic cough: age related causes to consider
Milk inhalation/reflux
Early months of
Asthma
life
Acute viral bronchiolitis
Asthma
Bronchitis
Whooping cough
(pertussis)
Toddler/preschool
Cystic fibrosis
child
Croup
Foreign body inhalation
Tuberculosis
Bronchiectasis
Asthma
Early school
Bronchitis
years
Mycoplasma pneumonia
Asthma
Adolescence Psychogenic
Smoking
Cough
Upper respiratory infection
Postnasal drip/sinusitis/rhinitis
Smoking
Inhaled irritants
Acute bronchitis
Chronic bronchitis/COPD

Cardiovascular:
• left ventricular failure
Cancer:
• lung cancer
• larynx
Infection:
• tuberculosis
• pneumonia
• influenza
• lung abscess
• HIV infection
• SARS (coronavirus)
Other:
• asthma
• cystic fibrosis
• foreign body
• pneumothorax

Atypical pneumonias
Gastro-oesophageal reflux (nocturnal)
Smoking (children/adolescents)
Bronchiectasis
Whooping cough (pertussis)
Interstitial lung disorders (e.g. idiopathic pulmonary fibrosis)
Sarcoidosis
Drugs (e.g. ACE inhibitors, beta blockers, inhaled steroids, sulfasalazine)

Anxiety and habit.
Key history
Determine the nature of the cough, especially associated symptoms such as the nature of the
sputum, breathlessness, wheezing and constitutional symptoms. Haemoptysis See ‘Haemoptysis
(in adults)’. History of smoking habits, past and present, and occupational history are essential.
Past history, especially respiratory and drug intake.
Key examination
• General examination including a search for enlarged cervical or axillary glands
• Careful examination of the lungs and cardiovascular system with inspection of sputum
Key investigations
More applicable if haemoptysis
• FBE/ESR/CRP
• Sputum cytology and culture
• Respiratory function tests
• Plain CXR and others as appropriate
Diagnostic tips
• Postnasal drip is the commonest cause of a persistent or chronic cough especially at
night.
• Cough may persist for many weeks following a URTI.
• Cough is the cardinal feature of chronic bronchitis.
• Unexplained cough >50 years is bronchial carcinoma until proved otherwise (esp. if a
history of smoking).
Crying and fussing in infants
Normal/hunger
Infantile ‘colic’
Teething
Viral URTI/illness
Otitis media
Constipation

Vascular:
• Cardiac failure
Infection:
• Meningitis/encephalitis
• Gastroenteritis
• Other systemic infection
Other:
• Gastro-oesophageal reflux/oesophagitis
• Injury esp. non-accidental, birthing

Severe nappy rash
Constipation
Cow’s milk intolerance

Lactose intolerance
Balanitis (males)
Rarities:
• Bowel obstruction/pyloric stenosis

• Intussusception
• Other congenital e.g. oesophageal atresia
Urinary tract infection

?hunger ?soiled napkin ?tiredness ?family dysfunction ?inattention
Key history
Obtain detailed account from parents of the crying pattern and duration, as well as the
circumstances of discomfort incl. feeding, time relationship to feeds and associations,
particularly vomiting or possetting, presumed abdominal discomfort, constipation, bowel actions
and fever. Establish if breastfeeding or providing other milk and food. Ask about recent
immunisation.
Key examination
• General features: appearance of the child, growth parameters and vital signs
• Abdominal examination esp. inspection, palpation and auscultation
• Examine skin looking for evidence of eczema and napkin rash
• Examine the ears, fontanelles
• Also assess the child’s temperament and coping abilities
Key investigations
Nil for most cases
Consider:
• urinalysis
• MCU
• FBE
• ESR/CRP
• stool analysis
• referral for upper GIT investigation
Diagnostic tips
The normal pattern is for crying to start increasing around 2 weeks of age, to peak around 2
months and then settle down 3–4 months of age.
Deafness and hearing loss
Impacted cerumen
Serous otitis media (glue ear)
Otitis externa
Otitis media
Congenital (children)
Presbyacusis

Neoplasia:
• acoustic neuroma
• temporal lobe tumours (bilateral)
• otic tumours
Infection:
• generalised infections (e.g. mumps, measles)

• meningitis
• syphilis
Other:
• perforated tympanic membrane

• cholesteatoma
• perilymphatic fistula (post-stapedectomy)
• Meniere syndrome

Foreign body
Temporal bone fracture
Otosclerosis
Head injury
Barotrauma
Noise-induced deafness
Rarities:
• Paget disease of bone

• multiple sclerosis
• osteogenesis imperfecta
Diabetes
Drugs (see list)
Thyroid disorder (hypothyroidism)

Unlikely.
Key history
Onset and progression of any deafness, noise exposure, drug history, swimming or diving, air
travel, head injury and family history. A recent or past episode of a generalised infection would
be relevant and the presence of associated aural symptoms such as ear pain, discharge, tinnitus
and vertigo. Enquire about the effect of noise.
Key examination
• Inspect the facial structures, skull and ears and the ear with an otoscope. Ensure that the
external auditory canal is clean
• Perform simple office hearing tests including tuning fork tests
Key investigations
• Audiometry and tympanometry
• Swab of any ear discharge for M&C
Diagnostic tips
• People with conductive deafness tend to speak softly, hear better in a noisy environment
and hear well on the telephone. The opposite applies for sensorineural deafness.
• Ototoxic drugs: alcohol, aminoglycosides e.g. streptomycin, neomycin, gentamicin,
tobramycin, chemotherapeutic agents, quinine, salicylates/aspirin excess, diuretics e.g.
ethacrynic acid, frusemide.
Diarrhoea
Acute:
• Gastroenteritis/infective enteritis
• Dietary indiscretion
• Antibiotic reaction
Chronic:
• Irritable bowel syndrome (IBS)

• Drug reactions (e.g. laxatives)
• Chronic infections

Neoplasia/cancer:
• colorectal cancer
• ovarian cancer
• peritoneal cancer
Infection:
• cholera
• typhoid/paratyphoid
• amoebiasis
• malaria
• enterohaemorrhagic E. coli enteritis
• HIV infection (AIDS)
Others
Inflammatory bowel disease:
• Crohn/ulcerative colitis
• pseudomembranous colitis
Intussusception
Pelvic appendicitis/pelvic abscess

Coeliac disease
Faecal impaction with spurious diarrhoea
Lactase deficiency
Giardia lamblia infection
Cryptosporidium infection
Malabsorption states (e.g. coeliac disease)
Vitamin C and other oral drugs
Nematode infections:
• strongyloides (threadworm)
• whipworm
• hookworm
Radiotherapy
Diverticulitis
Post-GIT surgery
Ischaemic colitis (elderly)
Rarities:
• Addison disease
• carcinoid tumours
• short bowel syndrome
• amyloidosis
• toxic shock
• Zollinger–Ellison syndrome
Diabetes
Drugs (see list)
Hyperthyroidism

Yes, diarrhoea may be a manifestation of anxiety state or irritable bowel syndrome.
Key history
Establish what the patient means by diarrhoea. Analyse the nature of the stools, frequency,
associated symptoms (e.g. abdominal pain) and constitutional symptoms such as fever and
weight loss. Drug history, travel history and family history.
Key examination
• Focus on the general state (esp. of severe gastroenteritis), the abdomen, rectum and skin
• Ideally the stool should be examined (note the presence of blood, mucus or steatorrhoea)
Key investigations
In some instances such as acute self-limiting diarrhoea nil is required. Consider:
• microscopy and culture of stool

• FBE
• ESR/CRP
• C. difficile tissue culture assay
• U&E
• specific tests for organisms
• endoscopy
• selective radiology (e.g. small bowel enema).
Diagnostic tips
• Giardiasis (profuse bubbly diarrhoea) is more common than realised.
• Remember spurious diarrhoea and the rectal examination in the elderly.
• IBS rarely causes nocturnal diarrhoea but causes recurrent pain in the right
hypochondrium.
• Some drugs that can cause diarrhoea: alcohol, antibiotics, digoxin, colchicine, cytotoxic
agents, H 2 -receptor antagonists, iron compounds, laxatives, metformin, sildenafil, statins,
thyroxine.
Diplopia
Binocular:
• Ocular nerve palsy (3,4,6) various causes

• CVA/TIA
• Ophthalmoplegic migraine
• Physiological (disparateness)
• Drug effect e.g. alcohol, benzodiapines
Monocular:
• Eye disorder e.g. cataract, refractive error, cornea

Vascular:
• CVA/TIA
Infection:
• Intraocular abscess
• Sinusitis
• Botulism
• HIV/AIDS
Tumour/cancer:
• Involving 3, 4 or 6 cranial nerves
Other:
• Facial bone trauma/head injury

• Guillain-Barré syndrome
Any orbital infiltration
Rarities:
• Multiple sclerosis
• Myasthenia gravis
• Orbital myositis
• Cavernous sinus thrombosis
Diabetes: mononeuritis
Drugs e.g. sedatives, opioids, alcohol
Thyroid/other endocrine: hyperthyroid

A consideration if nil findings. Some cases are idiopathic.
Key history
A careful history is required to determine nature of diplopia: if one or both eyes, intermittent,
constant or associated pain. Check for other neurological symptoms incl. other cranial nerve
dysfunction, and other associated general symptoms such as weight loss and fever. Check past
medical history incl. diabetes, hypertension and cerebrovascular disease, as well as drug history,
esp. alcohol or illicit, prescription and OTC drugs.
Key examination
• General features: appearance of patient, vital signs
• Inspection of the eyes and neck (goitre)
• Ocular motility
• Visual acuity
• Establish if binocular or monocular
• Perform the cover test
• Cranial nerves in general
• Other basic neurological examination
• Ophthalmoscopy
Key investigations
Nil for most cases
First line:
• urinalysis
• blood sugar
• FBE
• ESR/CRP
Consider:
• TFTs
• imaging if indicated (refer)
Diagnostic tips
Refer urgently if diplopia is binocular, of recent onset and persistent. Other ‘red flags’ incl. any
pupil involvement, pain, proptosis, any other neurological symptoms or signs.
Disturbed or agitated patient
The 4 Ds:
• dementia
• delirium (look for cause)
• depression
• drugs: toxicity, withdrawal

Cardiovascular:
• CVAs
• cardiac failure
• arrhythmia
• acute coronary syndromes
Neoplasia/cancer:
• cerebral
• cancer (e.g. lung)
Infection:
• septicaemia
• HIV infection
• infective endocarditis
Hypoglycaemia/diabetic ketoacidosis
Bipolar disorder/mania
Schizophrenia states
Anxiety/panic
Subdural/extradural haematoma
Alcohol intoxication/withdrawal
Illicit drug withdrawal (e.g. amphetamines)
Fluid and electrolyte disturbances
Faecal impaction (elderly)
Urinary retention (elderly)
Hypoxia
Pain syndromes (elderly)
Rarities:
• postictal state
• hypocalcaemia
• kidney failure
• hepatic failure
• prion diseases (e.g. Creutzfeldt-Jakob disease)
Depression
Diabetes (hypo and hyperglycaemia)
Drugs: iatrogenic/social illicit (see list)
Anaemia
Thyroid disorder (hypo and hyper)
Spinal dysfunction (severe pain in elderly)
UTI
Consider anxiety, depression, emotional deprivation or upset, change in environment, serious
personal loss.
Key history
The basis of the history is an accurate account from relatives or witnesses about the patient’s
behaviour. When communicating with the patient, speak slowly and simply, face them and
maintain eye contact. Note the past history and recent psychosocial history, including recent
bereavement, family upsets and changes in environment. Drug history is vital. Perform a mini
mental status examination.
Key examination
• Note the patient’s general demeanour, dress and physical characteristics
• Check vital signs
• Assess the patient’s ability to hear, speak, reason, obey commands, stand and walk
• Look for features of alcohol abuse, Parkinson disease and hypothyroidism
• Examine the neurological systems
• Pulse oximetry (if available)
Key investigations
For delirious or demented patients of unknown cause consider:
• MCU urine
• blood culture
• FBE/ESR
• blood glucose
• U&E, calcium and phosphate
• B12 and folate, vitamin D
• TFTs
• LFTs
• HIV test
• arterial blood gases
• CXR
• cerebral CT scan.
Diagnostic tips
• The cause may be single or multiple.
• Psychiatric causes include panic disorder, mania, major depression and schizophrenia.
• The key feature of dementia is impaired memory.
• The two key features of delirium are disorganised thought and inattention.
• Prescribed drugs that can cause antisocial behaviour: major and minor tranquilisers, anti-
Parkinson, cardiogenic, corticosteroids.
Dizziness/vertigo
Anxiety-hyperventilation
Postural hypotension
Simple faint—vasovagal
Acute vestibulopathy (V)—viral illness
Benign paroxysmal positional vertigo (V)
Motion sickness (V)
Post head injury (V)
Cervical dysfunction/spondylosis
Note: V = vertigo

Neoplasia/cancer:
• acoustic neuroma
• posterior fossa tumour
• other brain tumours, primary or secondary
Intracerebral infection (e.g. abscess)
Cardiovascular:
• arrhythmias
• aortic stenosis
Cerebrovascular:
• vertebrobasilar insufficiency
• brain stem infarct (e.g. PICA thrombosis)
Multiple sclerosis

Ear wax-otosclerosis
Arrhythmias
Hyperventilation
Alcohol and other drugs (incl. illicit, e.g. cocaine)
Cough or micturition syncope
Vertiginous migraine/migrainous vertigo
Parkinson disease
Meniere syndrome (overdiagnosed)
Rarities:
• Addison disease
• neurosyphilis
• autonomic neuropathy
• hypertension
• subclavian steal
• perilymphatic fistula
• Shy–Drager syndrome
Depression
Diabetes (hyper and hypoglycaemia)
Drugs (several)
Anaemia
Thyroid disorder (possible)
Spinal dysfunction
UTI (possible)

Very likely. Consider anxiety and/or depression.
Key history
Careful history to determine if the problem is vertigo or pseudovertigo (giddiness, faintness or
disequilibrium). Check for neurological symptoms, aural symptoms and visual symptoms.
Recent history of respiratory infection or head injury. Drug history including illicit drugs and
alcohol (?acute intoxication).
Key examination
• General examination including gait
• Cardiovascular, auditory and neurological examinations
• Hallpike manoeuvre and Epley test
• Forced hyperventilation test
Key investigations
• FBE
• b glucose
• audiometry
• ECG, ?Holter monitor
• Other tests according to history and examination
• Consider MRI, especially if acoustic neuroma or other tumour suspected
Diagnostic tips
• A sudden attack of vertigo in a young person after a recent URTI suggests vestibular
neuronitis.
• Dizziness is often multifactorial, especially in the elderly.
• Commonly prescribed drugs, especially antihypertensives, antidepressants, aspirin and
salicylates, glyceryl trinitrate, benzodiazipines, major tranquilisers, antiepileptics and
antibiotics, can cause dizziness.
Dyspepsia
Irritable upper GIT (functional dyspepsia)
Gastro-oesophageal reflux
Gastritis
Oesophageal motility disorder (dysmotility)

Cancer:
• stomach
• pancreas
• oesophagus
Cardiovascular:
• ischaemic heart disease

• congestive cardiac failure
Pancreatitis
Peptic ulcer (PU)

Myocardial ischaemia
Food allergy (e.g. lactose intolerance)
Pregnancy (early)
Biliary motility disorder
Other gall bladder disease

Post vagotomy
Duodenitis
Rarities:
• mesenteric ischaemia
• Zollinger–Ellison syndrome
• kidney failure
• scleroderma
Depression
Diabetes (rarely)
Drugs, esp. NSAIDs, aspirin

Anxiety and stress are common associations of which patients are often unaware. Consider
irritable bowel syndrome.
Key history
Clarify the exact nature of the presenting complaint: what the patient means by ‘indigestion’ or
‘heartburn’. Note the relationship of the symptoms to eating. In particular, care should be taken
to consider and perhaps exclude ischaemic heart disease. Analyse the presenting symptom
according to site and radiation, character of discomfort, aggravating and relieving factors and
associated symptoms. Drug history and past history is important, especially NSAID use.
Key examination
• This does not provide the key to the diagnosis, but perform very careful palpation and
inspection
• Look for evidence of anaemia and jaundice
Key investigations
Do not overinvestigate.
• The investigation of choice is gastroscopy, which is indicated for ‘alarm symptoms’ such
as dysphagia, bleeding and unexplained weight loss
• Test for Helicobacter pylori
Diagnostic tips
• Epigastric pain aggravated by any food and relieved by antacids indicates chronic gastric
ulcer.
• Pain before meals relieved by food indicates chronic duodenal ulcer.
• Triple loss of appetite, weight and colour is a feature of cancer of the stomach.
Dysphagia
Functional (e.g. ‘express’ swallowing, psychogenic)
Tablet-induced irritation
Pharyngotonsillitis
GORD/reflux oesophagitis

Neoplasia/cancer:
• cancer of the pharynx, oesophagus (esp.) stomach

• extrinsic tumour
AIDS (opportunistic oesophageal infection)
Stricture, usually benign peptic stricture
Scleroderma
Neurological causes:
• pseudobulbar palsy
• motor neurone disease (amyotrophic sclerosis)
• Parkinson disease

Foreign body
Drugs (e.g. phenothiazines)
Subacute thyroiditis
Extrinsic lesions (e.g. lymph nodes, goitre)

Upper oesophageal web (e.g. Plummer–Vinson syndrome)
Eosinophilic oesophagitis
Radiotherapy
Achalasia
Upper oesophageal spasm (mimics angina)
Rarities (some):
• Sjögren syndrome
• aortic aneurysm
• aberrant right subclavian artery
• lead poisoning
• cervical osteoarthritis (large osteophytes)
• other neurological causes
• other mechanical causes
Depression
Drugs
Thyroid disorder

Yes. Could be functional ?globus hystericus.
Key history
Analyse the nature of the symptom: difficulty in swallowing. Its origin is either oropharyngeal or
oesophageal. A careful history includes a drug history and psychosocial factors.
Key examination
• Focus on the patient’s general features, mouth, oropharynx, larynx, neck (esp.
lymphadenopathy and thyroid) and any abnormal neurological features especially cranial
nerve function and muscle weakness disorders
Key investigations
Consider:
• FBE
• oesophageal manometry study (manometry)
• endoscopy ± barium swallow
• CXR.
The primary investigation in suspected pharyngeal dysphagia is a video barium swallow, while
endoscopy is generally the first investigation in cases of suspected oesophageal dysphagia.
Diagnostic tips
• Dysphagia must not be confused with globus hystericus, which is the sensation of the
‘constant lump in the throat’ although there is no actual difficulty swallowing food.
• Mechanical dysphagia represents cancer until proved otherwise.
• Be careful of a change in symptoms in the presence of longstanding reflux (consider
stricture or cancer).
Dyspnoea, acute and chronic
Bronchial asthma
Bronchiolitis (children)
COPD
Ageing, lack of fitness
Left heart failure/CCF
Obesity

Cardiovascular:
• acute heart failure (e.g. AMI)

• acute coronary syndromes
• arrhythmia
• pulmonary embolism
• pulmonary hypertension
• dissecting aneurysm
• cardiomyopathy
• pericardial tamponade
• anaphylaxis
Neoplasia:
• bronchial carcinoma, other malignancy
Infection:
• SARS
• avian influenza
• pneumonia
• acute epiglottitis (children)
Respiratory disorders:
• inhaled foreign body

• upper airways obstruction
• pneumothorax
• atelectasis
• pleural effusion
• tuberculosis
• acute respiratory distress syndrome (ARDS)
Neuromuscular disease:
• infective polyneuritis (Guillain-Barré)

• poliomyelitis

Interstitial lung diseases:
• idiopathic pulmonary fibrosis

• extrinsic allergic alveolitis
• sarcoidosis
• drug-induced interstitial lung disease
Chemical pneumonitis
Metabolic acidosis
Radiotherapy
Kidney failure (uraemia)
Multiple small pulmonary emboli
Depression
Diabetes—Ketoacidosis
Drugs (see list)
Anaemia
Thyroid disorder (thyrotoxicosis)

Consider functional hyperventilation (anxiety and panic attacks).
Key history
Aim to differentiate between pulmonary causes such as COPD and asthma and cardiac failure.
Assess the rate of development of dyspnoea.
Key examination
• Careful inspection is mandatory. With patient stripped to waist observe for factors such
as cyanosis, clubbing, mental alertness, dyspnoea at rest, use of accessory muscles and
rib retraction
• Use auscultation to differentiate between crackles and wheezes
Key investigations
The two most important are CXR and pulmonary function test including pulse oximetry. Others
include:
• FBE/ESR
• arterial blood gases
• cardiology (e.g. ECG, echocardiography, enzymes and other medical imaging).
Diagnostic tips
• All heart diseases have dyspnoea on exertion as a common early symptom.
• Several drugs can produce a wide variety of respiratory disorders especially pulmonary
fibrosis and pulmonary eosinophilia. The main agents are amiodarone and cytotoxic
drugs.
• The abrupt onset of severe dyspnoea suggests pneumothorax or pulmonary embolism.
• Toxic agents that may cause hyperventilation are salicylate, methyl alcohol, theophylline
overdosage and ethylene glycol.
Dysuria
UTI (esp. cystitis)
Urethritis
Urethral syndrome—abacterial cystitis (female)
Vaginitis

Neoplasia:
• bladder
• prostate
• urethra
Infection:
• gonorrhoea
• chlamydia/others
• genital herpes
• prostatitis
Reactive arthritis
Calculi (e.g. bladder)

Menopause syndrome
Adenovirus urethritis
Prostatitis
Foreign bodies in lower urinary tract

Acidic urine
Acute fever
Interstitial cystitis
Urethral caruncle/diverticuli
Vaginal prolapse
Obstruction:
• benign prostatic hyperplasia

• urethral stricture
• phimosis
• meatal stenosis
Depression
Diabetes
Drugs
UTI

Consider psychosexual problems, anxiety and hypochondriasis.
Key history
It is important to determine whether dysuria is really genitourinary in origin and not attributable
to functional disorders, such as psychosexual problems. Disturbances of micturition are
uncommon in the young male and if present suggest sexually transmitted infection (STIs).
Key questions:
• Could you describe the discomfort?
• What colour is your urine?
• Does it have a particular odour?
• Have you noticed a discharge?
• If so, could it be sexually acquired?
• Do you find intercourse painful or uncomfortable (women)?
• Have you any fever, sweats or chills?
Key examination
• General inspection looking for evidence of kidney disease and vital signs
• Abdominal palpation to focus on the loins and suprapubic areas
• The possibility of STIs should be considered and this includes vaginal examination in the
female and rectal and genital examination in the male
• In the menopausal female the cause may be evident from a dry atrophic urethral opening,
a urethral caruncle or urethral prolapse
Key investigations
• Dipstick testing of the urine
• Microscopy or culture (midstream specimen of urine or suprapubic puncture in children)
• Urethral swabs or first pass urine for STIs
• Further investigations depend on findings
Diagnostic tips
• Urethritis causes pain at the onset of micturition and cystitis at the end.
• Suprapubic discomfort is a feature of bladder infection (cystitis).
• Unexplained dysuria could be a pointer to chlamydia urethritis.
Ear discharge (otorrhoea)
Acute otitis media with perforation
Chronic suppurative otitis media
Furuncle (boil) of ear canal
Infected otitis externa
Reactive skin conditions e.g. eczema
Liquified wax

Infection:
• Pseudomonas pyocyanea
• Cholesteatoma
• Herpes zoster oticus
• Mastoiditis
Cancer:
• Malignancy with discharge e.g. SCC
Other:
• Cerebrospinal fluid otorrhoea (fractured temporal bone)

• Necrotising otitis media
Foreign body with infection/liquidisation e.g. insects
Trauma ± blood
Rarities:
• Keratitis obliterans
• Branchial or salivary fistula
• Wegener’s granulomatosis

Factitious? Consider excessive manipulation of ear canal
Key history
• Nature of discharge: acute or chronic, clear or bloody, offensive
• Associated symptoms, esp. pain in ear or adjacent structures, fever, tinnitus,
dizziness/vertigo, hearing loss
• Use of ear drops and ear toilet
• Previous history of ear problems and ear surgery
• History of water sports, air travel, tropical residence or head injury
Key examination
Look for cause:
• Otoscopic view of ear and canal

• Inspection of surrounding structures e.g. mastoid
• Look for evidence of herpes zoster infection (sensory branch 7th cranial nerve)
Key investigations
First line:
• swab for M & C of ear discharge

• simple bedside hearing tests
Consider:
• X-ray mastoid
• audiometry
• wound swabs (if evidence infection)
• duplex ultrasound
• ankle brachial index
• biopsy
• KFTs
Diagnostic tips
Acute ear discharge is most likely due to otitis externa or perforated ear drum with otitis media.
Ear pain
Otitis media (viral or bacterial)
Otitis externa
Boils and furuncles of canal
TMJ arthralgia
Eustachian tube dysfunction

Neoplasia of external ear
Cancer of other sites (e.g. tongue, throat)
Herpes zoster (Ramsay—Hunt syndrome)
Acute mastoiditis
Cholesteatoma
Necrotising otitis externa

Foreign bodies in ear
Hard ear wax
Trauma including barotrauma
Dental abscess
Referred pain: neck, throat (e.g. tonsillitis)
Unerupted wisdom tooth and other dental causes
TMJ arthralgia
Chondrodermatitis nodularis helicus
Facial neuralgias, esp. glossopharyngeal
Post tonsillectomy:
• from the wound

• from TMJ due to mouth gag
Depression
Spinal dysfunction (cervical)

Unlikely, but always possible with pain. More likely in children. Consider factitious pain.
Key history
Assess the site of pain and radiation, details of the onset of pain, nature of the pain, aggravating
or reliving factors and associated features such as vertigo, tinnitus, sore throat and irritation of
the external ear. Ask about trauma, especially the use of a cotton bud to clean the ear.
Key examination
• The external ear with manipulation of the ear
• Check helix for chondrodermatitis nodularis helicus
• Palpate the face and neck to include the parotid glands, regional lymph nodes and skin
and temporomandibular joint (TMJ)
• Inspect both empty ear canals and tympanic membrane (TM) with the auroscope using
the largest possible earpiece
• Look for causes of referred pain: cervical spine, nose, postnasal space and mouth
including teeth
Key investigations
Seldom necessary.
• Consider hearing tests, audiometry

• Any ear discharge for MC but swabs of no value if the TM is intact
Diagnostic tips
• The pain of otitis media may be masked by fever in babies and young children.
• If an adult presents with ear pain but normal auroscopy, examine possible referral sites,
namely TMJ, mouth, throat, teeth and cervical spine.
Epigastric pain
GORD/gastritis
Gastric ulcer
Duodenal ulcer/duodenitis
Non-ulcer heartburn
Gallstones/biliary colic
Abdominal muscular strain
Irritable upper GIT

Vascular:
• Acute coronary syndromes esp. AMI

• Ruptured abdominal aortic aneurysm (AAA)
• Mesenteric artery ischaemia
Infection:
• Cholecystitis
• Hepatitis
• Lower lobe pneumonia
• Ascending cholangitis
Cancer/tumour:
• Cancer of stomach or pancreas

• Metastatic cancer
Other:
• Pancreatitis
• Perforated ulcer/viscus

Oesophageal spasm
Biliary motility disorder
Aerophagy
Rarities:
• Porphyria
• Addison disease
• Sickle cell disease
• Epigastric hernia
Depression
Drugs e.g. NSAIDs, antibiotics, bisphosphonates, alcohol
Spinal dysfunction—referred

Key history
Clarify the exact nature of the presenting complaint: the nature of the pain/discomfort,
indigestion or heartburn. Analyse any pain according to the SOCRATES formulation. Include
associated general symptoms such as weight loss, fever or vomiting. Examine past medical
history incl. peptic ulcer, diabetes, hypertension and cerebrovascular disease, as well as drug
history, esp. alcohol and NSAID use.
Key examination
• General features: appearance of patient and vital signs
• Abdominal examination, particularly inspection, palpation and auscultation
• Palpate for nodes in the neck (ca. stomach)
Key investigations
Nil for most cases.
First line:
• urinalysis
• FBE
• ESR/CRP
• Helicobacter pylori test
• upper GIT endoscopy
• ultrasound (?gallstones)
Consider:
• cardiac enzymes
• s lipase/amylase
• ECG
• CXR
• oesophageal manometry
• other imaging if indicated e.g. CT or MRI esp. if epigastric mass
Diagnostic tips
Epigastric pain aggravated by any food and relieved by antacids indicates chronic gastric ulcer.
Pain before meals relieved by food indicates chronic duodenal ulcer.
Epigastric pain waking the person soon after falling asleep (e.g. 3am) indicates gastric ulcer or
biliary colic. Pain can be referred from disorders of the heart, lungs, pancreas, biliary tract and
spine.
Epistaxis
Idiopathic: spontaneous from Little’s area
URTI: common cold/flu/sinusitis
Rhinitis: allergic and atrophic
Vestibulitis
Trauma (incl. nose picking, nose injury)
Drugs (e.g. anticoagulants, aspirin)

Vascular:
• hypertension and arteriosclerosis
Infection:
• systemic febrile illness (e.g. malaria)

• HIV/AIDS
Cancer/neoplasia:
• tumours of nose/sinuses/nasopharynx
• intracranial tumours
• leukaemia
Other:
• thrombocytopenia
• coagulopathy (e.g. haemophilia, liver disease)
Exposure to toxic agents
Vitamin deficiencies: C and K
Septal granulomas and perforations
Foreign bodies (esp. in children)
Cocaine abuse
Rarities:
• hereditary haemorrhagic telangiectasia
Drugs: anticoagulants, aspirin, nasal sprays Anaemia: aplastic anaemia
Key history
Recent trauma to nose. Significant past history (e.g. hypertension). Drug and alcohol history (e.g.
anticoagulants). Bleeding or bruising tendency.
Key examination
• Nasal airways and sinuses
• Skin for evidence of purpura or ecchymoses
• Lymph node areas and abdomen for hepatosplenomegaly
• Vital signs (esp. blood pressure)
Key investigations
Probably none. Consider:
• FBE
• clotting studies
• sinus X-ray
• INR
• CT scan (occasionally).
Diagnostic tips
• Recent onset of persistent bleeding in elderly points to carcinoma.
• Severe epistaxis is often caused by liver disease coagulopathy.
• Difficult-to-control posterior bleeding is a feature of the hypertensive elderly.
Erectile dysfunction
Ageing
Drugs esp. excess alcohol
Diabetes (autonomic dysfunction)
Stress/anxiety/depression

Vascular:
• Generalised arteriopathy esp. lower limbs
Infection:
• Generalised: viral, bacterial
Tumours:
• Pituitary fossa
Other:
• Systemic illness
• Chronic kidney disease

Pelvic trauma
Excessive cigarette smoking
Iatrogenic e.g. prostate surgery, drugs
Thrombosis corpus callosum

Rarities:
• Neurological e.g. MS
• Hypogonadism e.g. Klinefelter’s
• Anatomical e.g. tight frenulum, Peyroine’s disease
Depression including drugs
Diabetes
Drugs: various
Thyroid/other endocrine: several (see history)
Spinal dysfunction e.g. spinal cord pathology, cauda equina lesion

Consider psychosexual dysfunction incl. marital disharmony, performance anxiety
Key history
• Nature of onset including nature of sexual relationship
• Ask about nocturnal and early morning erections
• Drug history incl. alcohol, nicotine (4 times risk), street drugs (cocaine, cannabis),
pharmaceutical agents esp. antihypertensives (beta blockers, diuretics), hypolipidaemic
agents, antiandrogens (prostate cancer treatment), antidepressants, antipsychotics, H 2 -
receptor antagonists
Key examination
Genitourinary, cardiovascular and neurogenic examinations are important. This should include a
rectal examination; examination of the vascular and neurological status of the lower limbs; and
genitalia esp. the testicles and penis. Check the cremasteric and bulbocavernosus reflexes.
Key investigations
First line:
• glucose
• FBE
• free testosterone (androgen deficiency)
• thyroxine (hypothyroidism)
• prolactin
• LH
• FSH
• Urinalysis
Consider:
• LFTs esp. GGT (alcohol effect) and KFTs

• nocturnal penile tumescence
• Doppler flow studies
Diagnostic tips
Endocrine causes to consider include androgen/testosterone deficiency, hyperprolactinaemia and
hypothyroidism. Consider pituitary fossa tumour.
Eye, acute and subacute painless loss of

vision
Amaurosis fugax
Migraine
Retinal detachment
Acute glaucoma
‘Wet’ macular degeneration

Cardiovascular:
• central retinal artery occlusion

• central retinal vein occlusion
• hypertension (complications)
• CVA
Neoplasia:
• intracranial tumour
• intraocular tumour:
o — primary melanoma
o — retinoblastoma
o — metastases
Vitreous haemorrhage
AIDS
Temporal arteritis
Acute glaucoma
Benign intracranial hypertension

Acute glaucoma
Papilloedema
Optic neuritis
Uveitis
Intraocular foreign body
Diabetes (diabetic retinopathy)
Drugs (e.g. quinine, alcohol)
Thyroid disorder (hyperthyroidism)

Consider ‘hysterical’ blindness, although it is uncommon.
Key history
Past medical history including risk factors for cardiovascular disease and neurology such as
migraine and cerebrovascular disease. Family history and drug history.
Key examination
• Visual acuity: Snellen chart
• Ophthalmoscopic examination, tonometry
• Cardiovascular including carotid arteries
Key investigations
The vast majority of patients should be referred urgently to an ophthalmological service or stroke
unit. Initial tests are:
• FBE
• ESR/CRP
• blood sugar.
Diagnostic tips
• The visual disturbance may be the presenting symptoms of a general medical disorder
such as temporal (giant cell) arteritis, hypertension or diabetes.
• A cherry-red spot on the macula is pathognomonic of retinal artery occlusion.
Eye, gradual loss of vision
Cataract
Chronic glaucoma
‘Dry’, age-related macular degeneration
Gradual retinal detachment
Diabetic retinopathy

Vascular:
• hypertensive retinopathy
• cerebromacular degeneration
Infection:
• syphilis
• onchocerciasis (filariasis)
Cancer/neoplasia:
• intraorbital tumours
• intracranial tumours
• choroid melanoma
Other:
• optic neuritis (multiple sclerosis)

• Paget disease of skull
Retinitis pigmentosa
Drug toxicity (e.g. quinine, methanol, arsenic)
Rarities:
• choroid retinitis
• vitamin A deficiency
• Leber hereditary optic atrophy
Key history
Past history including risk factors for cardiovascular disease, family history, drug history and
associated symptoms or problems.
Key examination
• Visual acuity, ophthalmoscopic examination, tonometry, although early ophthalmological
referral is recommended
Key investigations
Initial tests are:
• FBE
• ESR/CRP
• blood sugar
• syphilis serology (if clinically indicated).
Diagnostic tips
• Keep the big three causes in mind—cataract, chronic glaucoma and age-related macular
degeneration—and refer for shared care.
• In the older patient whose cataract is not significantly improved with the pinhole test
consider macular degeneration.
Eye, red and tender
Conjunctivitis:
• bacterial
• adenovirus
• allergic

Acute glaucoma
Uveitis:
• acute iritis
• choroiditis
Corneal ulcer
Corneal injury: abrasion/foreign body
Herpes simplex keratitis
Microbial keratitis (e.g. fungal, amoeba, bacterial)
Herpes zoster ophthalmicus
Penetrating injury
Endophthalmitis
Orbital cellulitis
Scleritis/episcleritis
Foreign body (esp. IOFB)
Trauma
Ultraviolet light ‘keratitis’
Blepharitis
Rarities:
• cavernous sinus arteriovenous fistula

• primary tumour of eye
Drugs (hypersensitivity)
Thyroid disorder (hyperthyroidism)
Key history
The five essentials of the history are:
• history of trauma, especially as indicator of intraocular foreign body (IOFB)

• vision
• the degree and type of discomfort
• presence of discharge
• presence of photophobia.
Consider association with spondyloarthropathies.

Key examination
When examining the unilateral red eye keep the following diagnoses in mind:
• trauma
• foreign body, including IOFB
• corneal ulcer
• iritis (uveitis)
• viral conjunctivitis (commonest type)
• acute glaucoma
The four essentials of the examination are:
• testing and recording vision

• meticulous inspection under magnification (slit lamp is ideal)
• testing the pupils
• testing ocular tension
Key investigations
• May include swab of discharge for MC, visual acuity
• ESR/CRP
• HLAB27
• Consider specialist referral
Diagnostic tips
• A purulent discharge indicates bacterial conjunctivitis.
• A clear or mucus discharge indicates viral or allergic conjunctivitis.
• Be alert for the unilateral red eye: think beyond the conjunctivitis trio. It may be a corneal
ulcer, keratitis, foreign body, trauma, uveitis or acute glaucoma.
Facial pain
Dental pain:
• caries
• periapical/dental abscess
• fractured tooth
Maxillary/frontal sinusitis
Herpes zoster (shingles)

Cardiovascular:
• myocardial ischaemia
• aneurysm of cavernous sinus
• internal carotid aneurysm
• ischaemia of posterior inferior cerebellar artery
• temporal arteritis
Cancer/neoplasia:
• cancer: mouth, sinuses, posterior fossa, nasopharynx, tonsils, tongue, larynx

• metastases: orbital, base of brain, bone
Infection:
• orbital cellulitis
• erysipelas
• periapical abscess → osteomyelitis
• acute sinusitis → spreading infection
TMJ dysfunction
Migraine variants:
• facial migraine
• chronic paroxysmal hemicrania
Atypical facial pain
Eye disorders:
• glaucoma
• iritis
• optic neuritis
Chronic dental neuralgia
Facial bone diesease
Parotid gland: mumps, cancer, sialectasis, abscess
Acute glaucoma (upper face)
Cranial nerve neuralgias:
• post-herpetic neuralgia
• trigeminal neuralgia
• glossopharyngeal neuralgia
Depression
Spinal dysfunction

Quite probably. Atypical facial pain has underlying psychogenic elements.
Key history
Diagnosis of virtually all types of facial pain must be based entirely on the history. Include the
typical pain analysis, especially site and radiation.
Key examination
• Palpate the face and neck to include the parotid glands, eyes, regional lymph nodes and
skin
• Inspect the TMJs and cervical spine
• Carefully inspect the nose, mouth (esp. each tooth), pharynx and postnasal space
• Inspect the sinuses with transillumination
• Perform a neurological examination of the cranial nerves
Key investigations
Referral may be appropriate. The association of tumours with neuralgias may have to be
investigated. Radiological investigations to consider include:
• plain X-rays of the paranasal sinuses

• CT scans
• MRI
• orthopantomograms.
Diagnostic tips
• Facial pain never crosses the midline; bilateral pain means bilateral lesions.
• Malignancy must be excluded in the elderly with facial pain.
• Problems from the molar teeth, especially the third (wisdom) commonly presents with
peri-auricular pain and pain in the posterior check.
• Don’t overdiagnose sinusitis: many URTIs may produce mild facial ache (vacuum
effect).
Falls in the elderly
Environmental hazards e.g. slipping, tripping
Postural instability e.g. knees, hips, Parkinson
Visual e.g. glaucoma, macular degeneration
Medication esp. iatrogenic

Vascular:
• Cerebral insufficiency incl. TIAs, stroke

• Acute coronary syndromes
• Cardiac arrhythmias e.g. sick sinus syndrome
• Subdural or extradural haematoma
Infection:
• Any systemic infection esp. sepsis

• Any febrile illness
Tumour/cancer:
• Cerebral tumour
Other:
• Kidney failure
• Head injury
• Cognitive impairment e.g. dementia, delirium
• Fluid and electrolyte disturbance
Parkinson disease—early onset
Peripheral neuropathy
Gait and foot disorders
Labyrinthine e.g. BPPV, labyrinthitis
Rarities:
• Vitamin deficiency esp. Vit. D

• Cerebellar degeneration
• Post prandial hypotension
Depression
Diabetes: hypoglycaemia; neuropathy
Drugs (many—see history)
Anaemia
Thyroid/other endocrine: Addison D, hypothyroid?
Spinal dysfunction esp. myelopathy
Urinary tract infection—nocturia

Highly likely, consider conversion reaction.
Key history
A careful history is required including an interview with family members and any witnesses to
the fall. Investigate the onset, environment and circumstances of the fall.
Consider seizure and loss of consciousness, and situational factors such as rushing to bathroom,
climbing stairs or ladder. Incl. accounts of any witnesses to the fall.
Questions should incl. any premonitory or associated symptoms e.g. vertigo, lightheadedness,
palpitations, chest pain dyspnoea, visual disturbance, possible unusual or disturbed behaviour.
Gather past and recent medical history incl. diabetes, hypertension, cerebrovascular disease; as
well as a drug history, esp. alcohol or illicit drugs, prescription agents esp. sedatives
antidepressants, hypotensives, hypoglycaemics, antipsychotics, diuretics, NSAIDs. Check
thyroid status.
Key examination
• General features: appearance of patient incl. central cyanosis, hydration status, vital signs
incl. pulse, BP (supine and standing) and temperature
• Look for and exclude obvious extrinsic causes of falls
• Comprehensive CVS examination
• Examine ears, eyes, oral cavity, head and neck, spine, extremities esp. feet
• Neurological examination including muscle features, sensation, coordination, balance and
gait
• Mini mental state examination
Key investigations
First line:
• urinalysis
• blood sugar
• pulse oximetry
• FBE & ESR
• U&E
• ECG (or 24 hour monitor).
Consider others according to history and findings:
• LFTs (γGT)
• TFT
• echocardiography
• spinal X rays
• CT or MRI if indicated
• Doppler studies
Diagnostic tips
Consider rules of 7 in elderly patient: check mental status, eyes, ears, mouth (?dentition,
xerostomia), bladder and bowels, locomotion including feet and medication. Ideally, visit the
home to assess patient’s environment and home support, incl. examination of the medicine
cabinet.
Fever in the returned traveller
Malaria
Viral respiratory illness (e.g. influenza)
Bacterial pneumonia
Hepatitis (may be subclinical)
Gastroenteritis/diarrhoeal illness
Dengue

Malaria
Tuberculosis
Typhoid
Viral haemorrhagic diseases (e.g. Ebola, Lassa)
Encephalitis
Meningococcal meningitis
Melioidosis
Amoebiasis (liver abscess)
HIV seroconversion illness

Ascending cholangitis
Infective endocarditis
Cytomegalovirus
Epstein--Barr virus (glandular fever)
Dengue fever
Lyme disease
Bronchopneumonia
Ross River fever
Rarities:
• chikungunya
• Legionnaire disease
• schistosomiasis
• African trypanosomiasis
• typhus
• Rift Valley fever
• spotted fever
• yellow fever
• other haemorrhagic fevers
Drugs (reaction to antimalarials)
Key history
Ask about itinerary, length of stay, exposure to mosquitoes and possible contact with infectious
diseases. Associated symptoms, especially diarrhoea, abdominal pain, rash and other skin
lesions. Past history, prophylaxis (incl.immunisation) and drug history (incl. antimalarial
therapy).
Key examination
• General features
• Vital signs
• Neck for neck stiffness
• Skin and lymph node sites
• Respiratory and cardiovascular examination
• Abdominal examination, especially liver and spleen
Key investigations
• FBE (?eosinophils)
• ESR
• Blood culture
• Urine MC
• Stool MC
• LFTs
• Thick and thin blood films
• New malaria test
• Dengue serology
• CXR
• Tubercular skin test and interferon gamma release assay (for suspected TB)
• Specific tests for suspected diseases, e.g. Ebola, influenza
Diagnostic tips
• All fever in a returned traveller is malaria until proved otherwise.
• Three causes of a dry cough (in the absence of chest signs) are malaria, typhoid and
amoebic liver abscess.
• Be vigilant for meningitis and encephalitis.
Fever that is prolonged
Pyogenic abscess (anywhere e.g. liver, pelvis)
Pneumonia (viral, bacterial, atypical)
Epstein–Barr mononucleosis
Viral upper respiratory tract infection
Urinary infection (incl. chronic pyelonephritis)

Vascular:
• vasculitides (polyarteritis nodosa, giant cell arteritis/polymyalgia)
Infection:
• HIV/AIDS
• malaria and other tropical diseases
• zoonoses (e.g. leptospirosis, Q fever, listeriosis)
• typhoid/paratyphoid fever
• tuberculosis
• osteomyelitis
• chronic septicaemia/bacteraemia
o Lyme disease
o Syphilis (secondary)
Cancer:
• lymphoma and leukaemia

• solid cancers (e.g. lung, kidney)
• disseminated
Other:
• inflammatory bowel disease (e.g. Crohn)

Connective tissue disorder (e.g. rheumatoid arthritis, systemic lupus erythematous)
Sarcoidosis
Drug idiosyncrasies
Rarities:
• factitious fever
Note: Up to 20% remain unknown. FUO is fever < 38.3°C for at least 3 weeks.
Key history
Include past history, occupation, travel history, sexual history, IV drug use (leads to endocarditis
and abscesses), animal contact, medication and other relevant factors. Enquire about associated
symptoms such as pruritus, a skin rash, abdominal pain and diarrhoea, and weight loss. Note the
fever pattern. The history may need to be repeated.
Key examination
• Note general features and vital signs
• Check skin (rash, vesicles or nodules), eyes, temporal arteries, sinuses, teeth and oral
cavity, heart (note any murmurs), lungs, abdomen (enlarged or tender liver, spleen,
kidney), rectal and pelvic examination, lymph nodes (esp. cervical), urinalysis.
Key investigations
The basics are:
• FBE
• ESR/CRP
• CXR and sinus films
• urine MC
• routine blood chemistry
• LFTs
• blood culture.
Other tests depend on clinical pointers (e.g. specific organisms, lymph node biopsy, HIV,
tuberculosis, connective tissue auto-antibodies).
Diagnostic tips
• Prolonged fever is usually an uncommon presentation of a common disorder (unless
recent travel, esp. to tropics).
• Fever in the elderly is sepsis until proved otherwise (esp. lungs and urinary tract).
• The diagnosis of septicaemia can be easily missed, especially in small children, the
elderly and the immunocompromised.
Fits, faints and funny turns
Anxiety related/hyperventilation
Vasovagal syncope
Breath-holding attacks (children)

Cardiovascular:
• dysrhythmias, e.g. SVT

• acute coronary syndrome/silent AMI
• aortic stenosis
• postural orthostatic tachycardia syndrome (POTS)
Cerebrovascular:
• TIAs
Neoplasia:
• space-occupying lesions
Infections:
Hypoglycaemia
Atypical migraine
Cardiac arrhythmias/long QT syndrome
Simple partial seizures
Complex partial seizures
Atypical tonic--clonic seizures
Drugs/alcohol/marijuana/illicit drugs
Electrolyte disturbances (e.g. hypokalaemia)
Hypoxia
Sleep disorders
Transient global amnesia
Micturition/cough syncope
Rarities:
• atrial myxoma
• Stokes–Adams attacks
Depression
Diabetes (hypoglycaemia, ketoacidosis)
Drugs
Anaemia
Endocrine (Addison disease, hypothyroidism)
Spinal dysfunction (cervical spondylosis)

Highly likely. Psychogenic-pseudo-seizures and ‘communication’ disorders quite significant.
Key history
Fundamental to diagnosis. A reliable eyewitness account of the ‘turn’ is invaluable. Determine
what the patient means by ‘funny turn’. Evaluate the mental, personal and social factors. Assess
three components: lead-up to the episode, description of the episode and post-episode events.
Consider onset, precipitation factors and associated symptoms; also drug history and past history,
especially substance abuse.
Key examination
• Evaluate mental state, cerebrovascular/cardiovascular status, cervical spine
• Look for evidence of anaemia, alcohol abuse and infection
Key investigations
Consider:
• FBE
• ESR/CRP
• blood sugar
• U&E
• ECG
• 24-hour ambulatory cardiac monitor
• EEG or video EEG
• selected radiology (e.g. carotid duplex Doppler scan).
Diagnostic tips
• The commonest cause of ‘funny turns’ is lightheadedness, often related to psychogenic
factors such as anxiety, panic and hyperventilation. Patients usually call this dizziness.
• Migraine is a great mimic and can cause confusion in diagnosis.
• The more bizarre the description of a ‘funny turn’ the more likely a functional problem is
the cause.
Foot and ankle pain
Acute or chronic foot strain
Sprained ankle
Osteoarthritis (esp. great toe – hallux rigidus)
Plantar fasciitis
Achilles tendonopathy
Tibialis posterior tendonopathy
Wart, corn or callus
Ingrowing toenail/paronychia

Vascular insufficiency:
• small vessel disease
Neoplasia/cancer:
• osteoid osteoma
• osteosarcoma
• synovial sarcoma
• acral lentiginous melanoma
Infection (rare):
• actinomycosis
• osteomyelitis
Rheumatoid arthritis
Complex regional pain syndromes
Ruptured Achilles’ tendon
Ruptured tibialis posterior tendon

Foreign body (especially children)
Gout
Nerve syndromes:
• Morton neuroma
• tarsal tunnel syndrome
• deep peroneal nerve
Chilblains
Stress fracture (e.g. navicular)
Erythema nodosum
Rarities:
• spondyloarthropathies
• osteochondritis: navicular (Köhler), metatarsal head (Freiberg), calcaneum (Sever)
Glomus tumour (under nail)
Paget disease
Diabetes
Drugs
Spinal dysfunction

A non-organic cause warrants consideration with any painful condition.
Key history
Ask about the quality of the pain, its distribution, mode of onset, periodicity, relationship to
weight-bearing and associated features such as swelling or colour change. Enquire about pain in
other joints including sacroiliac joints.
Key examination
• Follow the inspection, palpation, movement and test function approach
• Test active and passive movements of the ankle (talar) joint, hindfoot (subtalar) joint and
mid-foot (midtarsal) joint
• Check the peripheral circulation and perform a neurological examination including
sensation, motor strength and reflexes
Key investigations
Consider:
• FBE
• ESR/CRP
• rheumatoid arthritis tests
• blood glucose
• uric acid
• nerve conduction studies and imaging (e.g. plain X-ray—compare both sides)
• ultrasound
• MRI
• radionuclide scans.
Diagnostic tips
• Good quality plain X-rays are important if there is doubt about the diagnosis of a painful
foot.
• Foot strain is probably the commonest cause of podalgia.
• All the distal joints of the foot may be involved in arthritic disorders.
Haematemesis
Chronic peptic ulcer (stomach and duodenum) 50%
Acute gastric ulcers/erosions 20%
Oesophagitis (incl. GORD)
Mallory--Weiss (emetogenic) syndrome
Drugs: aspirin, NSAIDs, anticoagulants, clopidogrel, NOACs

Vascular:
• oesophageal varices
• blood dyscrasias, e.g. aplastic anaemia
• vascular malformation/angiodysplasia
• hereditary coagulopathy
Cancer:
• gastric or oesophageal
Other:
• chronic liver disease

Stomach ulcer
Swallowed blood (e.g. epistaxis)

Collagen diseases (e.g. scleroderma)
Rarities:
• ruptured oesophagus
• hereditary haemorrhagic telangiectasia
• scurvy
• ingested poisons (e.g. acid, alkali, arsenic)
• gastric antral vascular ectasia
Key history
• Nature of vomitus from fresh blood to ‘coffee grounds’
• Is bleeding arising from the mouth, nose or pharynx?
• Indigestion, heartburn or stomach pains
• Associated symptoms (e.g. weight loss, jaundice)
• Any bleeding problems
• Drug history including alcohol, NSAIDs, antiplatelet agents, warfarin, steroids
Key examination
• Patient’s general state including circulation, vital signs
• Abdominal examination and rectal examination
• Evidence of liver disease
Key investigations
• Upper GIT endoscopy diagnoses bleeding source in 80%
• FBE
• LFTs including © GT
• Helicobacter pylori tests
• Imaging (e.g. plain erect X-ray, as indicated)
Diagnostic tips
• Melaena occurs in 50% of cases of haematemesis.
• Oesophageal bleeding tends to give vomiting fresh blood.
• ‘Coffee grounds’ vomitus indicates contact with gastric acid.
Haematuria
Infection:
• cystitis (both sexes)/urethrotrigonitis (female)

• urethritis (male)
• prostatitis (male)
Calculi-kidney, ureteric, bladder
Bladder tumour

Cardiovascular:
• kidney infarction
• kidney vein thrombosis
• prostatic varices
Neoplasia/cancer:
• kidney tumour
• urothelial: bladder, kidney, pelvis, ureter
• prostate cancer
Infection:
• kidney tuberculosis
• acute glomerulonephritis
• blackwater fever (falciparum malaria)
IgA nephropathy
Kidney papillary necrosis
Other kidney disease

Urethral prolapse/caruncle
Pseudohaematuria (e.g. beetroot, porphyria)
Benign prostatic hyperplasia
Trauma: blunt or penetrating
Foreign bodies
Bleeding disorders
Haemorrhagic cystitis
Exercise (esp. long distance running)
Radiation cystitis
Menstrual contamination
Rarities:
• hydronephrosis
• schistosomiasis (bilharzia)
• polycystic kidneys
• kidney cysts
• endometriosis (bladder)
• systemic vasculitides
Drugs (cytotoxics, anticoagulants) UTI

Consider artefactual haematuria.
Key history
Is it really haematuria? Red discolouration can be due to haemolysis or red food dye. The history
should include nature of haematuria, associations such as pain, sexually transmitted infections,
dysuria and frequency. Drug history, athletic history, urological history, sexual history, recent
trauma history, travel history.
Key examination
• General examination and vital signs, especially BP
• Cardiovascular examination to exclude possible kidney embolisation
• Abdomen examination especially for a palpable enlarged kidney or spleen
• Suprapubic examination for bladder tenderness or enlargement
• Consider rectal examination in men and vaginal examination in women
Key investigations
• Urine analysis
• Urine MC
• Urine cytology
• FBE/ESR
• Appropriate radiology (e.g. intravenous urogram, intravenous pyelogram, ultrasound.
• Direct imaging (e.g. cystoscopy)
Diagnostic tips
• Macroscopic haematuria is always abnormal except in menstruating women.
• Common sources of macroscopic haematuria are the bladder, urethra, prostate and
kidney.
• Joggers and athletes engaged in very vigorous exercise can develop transient microscopic
haematuria.
• Common urological cancers that cause haematuria are the bladder (70%), kidney (17%),
kidney pelvis or ureter (7%) and prostate (5%).
• The key radiological investigation is the intravenous urogram (pyelogram).
• Sometimes blood in the urine can come from the rectum or vagina.
• Painless frank haematuria is an ominous sign.
Haemoptysis in adults
Acute chest infection:
• URTI (24%)
• bronchitis
Chronic bronchitis
Trauma: chest contusion, prolonged coughing
Cause often unknown (22%)

Vascular:
• pulmonary infarction/embolus
• LHF / pulmonary oedema
• mitral stenosis
Infection:
• lobar pneumonia (rusty sputum)

• tuberculosis
• lung abscess
Cancer/tumour (4%):
• bronchogenic carcinoma
• tumour of the larynx or trachea
Other:
• blood disorders including anticoagulants

Foreign body
Bronchiectasis (13%)
Iatrogenic (e.g. endotracheal intubation)
Spurious haemoptysis (blood from nose or throat)
Rarities:
• idiopathic pulmonary haemosiderosis

• pulmonary AV malformation
• Goodpasture syndrome
• connective tissue disorder
Key history
Presenting symptom clarification—is it haemoptysis, haematemesis or bleeding from the nose or
throat? General symptoms (e.g. weight loss, fever, pain, esp. pleuritic pain). Respiratory and
cardiac history including past history and exposure to TB (e.g. refugees). Drug history especially
smoking, alcohol, anticoagulation.
Key examination
• General appearance and vital signs
• Full respiratory and cardiovascular examination including upper airways and mouth
• Check legs for evidence of deep venous thrombosis
Key investigations
• Chest X-ray
• FBE
• ESR/CRP
• Sputum M&C
• Other tests (e.g. CT, bronchoscopy, ECG, echocardiogram, ventilation/perfusion scan)
according to clinical findings
Diagnostic tips
• Blood originating from any area can be aspirated throughout lung.
• Bright red haemoptysis in a young person may be the initial symptom of pulmonary TB.
• Large haemoptyses are usually due to bronchiectasis or TB.
• The commonest causes of haemoptysis are URTI (24%), acute or chronic bronchitis
(17%), bronchiectasis (13%), TB (10%). Unknown causes total about 22%.
Hair loss
Androgenetic alopecia (male pattern baldness)
Alopecia areata (diffuse type)
Telogen effluvian (incl. postpartum)
Anagen effluvian (esp. cytotoxic therapy)
Seborrhoeic dermatitis

Infection:
• tinea capitis
• bacterial folliculitis
• secondary syphilis
• post-febrile state
Cancer:
• treatment for cancer
Other:
• systemic disease (e.g. lupus)

Rarities:
Heavy metal poisoning
Nutritional:
• severe dieting
• malnutrition
• zinc/iron deficiency
Drugs (cytotoxics, anticoagulants, anti-epileptics, amphetamines, anti-thyroid agents, various
hormones, cessation OCP)
Thyroid/other endocrine (hypothyroidism)

Emotional stress → telogen effluvium. Trichotillomania.
Key history
• Onset, duration, quantity and rate of loss
• Localised or generalised loss
• Characteristics of hair (e.g. scales, white bulbs)
• Associated symptoms (e.g. pruritus, scaling, pustules)
• Systems review including fever, acute illness, surgery, stressors
• Endocrine features
• Past history including skin disorders, cancer, thyroid disorders
• Family history of hair loss
• Drug history
Key examination
• General review with emphasis on endocrine system and examination of scalp
• Look for exclamation mark hair, ‘white bulb’ hair, state of bald patch (clean, scaly,
scarred or inflamed) and the unusual pattern of trichotillomania
Key investigations
Consider:
• FBE/ESR
• pituitary hormones (FSH/LH/prolactin/TSH)
• hair pull test
• trichogram
• scalp biopsy
• skin scrapings and hair sample for fungal microsurgery and culture.
Diagnostic tips
• Androgenetic (male pattern and female pattern hair loss) is the most common type.
• Microscopic examination (light or electron) may be required for definitive diagnosis.
• For patchy loss consider alopecia areata and trichotillomania.
• Generalised loss: consider telogen effluvium, systemic disease and drugs.
• In telogen effluvium, the traumatic event has preceded the hair loss by about 2 months
(peak loss at 4 months). ‘White bulbs’ are diagnostic.
Halitosis
• Dietary habits
• Poor oral hygiene
• Oro-dental disease (esp. gingivitis, discharging abscess)
• Dry mouth (e.g. on waking)
• Smoking/alcohol

Malignancy
• lung, oropharynx, larynx, stomach, nose, leukaemia
Pulmonary tuberculosis
Quinsy
Lung abscess
Blood dyscrasias/leukaemia
Uraemia
Hepatic failure

Nasal and sinus infection
Tonsillitis
Mouth breathing
Systemic infection
Appendicitis
Bronchiectasis
GORD/Hiatus hernia
Rarities:
• pharyngeal and oesophageal diverticula

• Sjögren syndrome
• scurvy
Depression
Diabetes (acetone)
Drugs (e.g. antidepressants, isosorbide)

Possible manifestation of psychogenic disorder (e.g. depression).
Key history
• General health
• Respiratory history
• Gastrointestinal history including dry mouth and reflux
• Dental history
• Drug history including OTC preparations, alcohol and smoking
• Dietary history: ask about onions, garlic, peppers, curries, spicy salami and similar meats,
strong cheeses and water intake
• Psychosocial history
Key examination
• Orodental inspection, also oropharynx, nose and sinuses
• Respiratory system
• Abdominal examination
Key investigations
• FBE
• ESR/CRP
• Urine analysis
• Blood sugar
• Kidney function tests
• Liver function tests
• X-ray of sinuses
• Consider CT scan sinuses
Diagnostic tips
• If cause is unknown refer to a dental surgeon; consider an ENT opinion.
• Bacterial putrefaction of dental and food debris plus inflammation of the gums are largely
responsible for oral malodour.
• Smoking, alcohol and a dry mouth all aggravate the problem.
• One survey indicated that 87% had an oral cause, 8% ENT and 5% an unidentified cause.
Hallucinations
Drugs: illicit or prescribed
Schizophrenia
Febrile delirium
Affective (mood) disorders
Drug withdrawal inc. alcohol, hypnotics
Dementias esp. Lewy body disease

Vascular:
• Cerebrovascular disease
• Migraine (luminous)
Infection:
• Encephalitis/meningitis
• Septicaemia
• Any serious febrile illness
Tumours:
• Cerebral tumours
• Cancer treatment
Other:
• Hypoxia
• Liver failure
• Metabolic/electrolyte imbalance
• Dehydration

Major depression
Extreme fatigue
Vitamin deficiency esp. B group
Seizure disorders esp. complex partial
Rarities:
• Narcolepsy
• Post-concussion
• Bereavement
• Multiple sclerosis
Depression
Diabetes
Drugs: iatrogenic/social–illicit
Thyroid/other endocrine: hypothyroid?
Urinary tract infection esp. elderly

Consider conversion disorder (hysteria); fabrication.
Key history
A careful history is required, esp. current history incl. general health, febrile illness,
psychological issues, neurological features, nutrition and head injury. Elicit type of hallucination:
auditory, visual, olfactory, tactile, hypnogogic or hypnopomic. Examine past, family and
psychosocial history, as well as any history of cerebrovascular disease, diabetes, hypertension or
migraine. Check thyroid symptoms, particularly for hypothyroidism. Also examine drug history:
prescribed; OTC; alcohol; social esp. marijuana, opioids, amphetamines, LSD, petrol sniffing.
Key examination
• General features: appearance of patient, vital signs
• General respiratory, neurological and cardiovascular examination
• Pulse oximetry
Key investigations
First line:
• urinalysis
• blood glucose
• FBE
• U&E
Consider:
• LFTs (γGT)
• ECG
• KFTs
• cerebral imaging
Diagnostic tips
Pay close attention to drugs use, esp. alcohol, caffeine, narcotics and illicit agents
Auditory hallucinations – incl. schizophrenia; depression; bereavement.
Visual: organic disease
Olfactory: complex partial seizures (temporal lobe)
Tactile: drugs (alcohol, opioids e.g. cocaine, amphetamines esp. ‘ice’)

Headache
Acute:
• respiratory infection
Chronic:
• tension-type headache
• combination headache
• migraine
• transformed migraine

Cardiovascular:
• subarachnoid haemorrhage
• intracranial haemorrhage
• carotid or vertebral artery dissection
• temporal arteritis
• cerebral venous thrombosis
Neoplasia:
• cerebral tumour
• pituitary tumour
Infection:
• meningitis (esp. fungal)

• encephalitis
• intracranial abscess
Haematoma: extradural/subdural
Glaucoma
Benign intracranial hypertension

Cervical spondylosis/dysfunction
Dental disorders
Refractive errors of eye
Sinusitis
Ophthalmic herpes zoster (pre-eruption)
Exertional headache
Hypoglycaemia
Post-traumatic headache (e.g. post-concussion)
Post-spinal procedure (e.g. epidural, lumbar puncture)
Sleep apnoea
Rarities:
• Paget disease
• post-sexual intercourse
• cluster headache
• Cushing syndrome
• Conn syndrome
• Addison disease
• dysautonomic cephalgia
Depression
Diabetes
Drugs (see list)
Anaemia
Thyroid disorder and other endocrine (as above)
Spinal dysfunction (cerviogenic)
UTI

Quite likely if there is an underlying psychogenic disorder.
Key history
A full description of the pain including a pain analysis should be obtained, especially associated
symptoms. It is useful to get the patient to prepare a diary with a grid plotting the relative pain
intensity with time of day. Family history, psychosocial history and drug history.
Key examination
• Use the basic tools of trade: thermometer, sphygmomanometer, pen torch, diagnostic set
with ophthalmoscope and stethoscope
• Inspect the head, temporal arteries and eyes
• Areas to palpate include the temporal arteries, the facial and neck muscles, the cervical
spine and sinusitis, teeth and TMJs
• Look for signs of meningeal irritation and papilloedema
• A mental state examination is advisable
• Perform a basic neurological examination
Key investigations
Consider:
• FBE
• ESR/CRP
• selective radiography (e.g. skull X-ray, sinus X-ray, CT scan or MRI scan).
Diagnostic tips
• Hypertension is an uncommon cause of headache.
• ‘Combination headaches’, which can last for days, have a mix of components such as
tension, depression, vascular headache and drug dependence.
• A patient >55 years presenting with unaccustomed headache probably has an organic
cause.
• Drugs that may cause headache: alcohol, analgesics (rebound), caffeine,
antihypertensives (several), COCP, corticosteroids, NSAIDs (esp. indomethacin),
vasodilators esp. nitrates, sildenafil.
Hip and buttock pain
Traumatic muscular strains
Referred pain from spine
Greater trochanteric pain syndrome
Osteoarthritis of hip

Cardiovascular:
• buttock claudication
Neoplasia:
• metastatic cancer
• osteoid osteoma
Infection:
• osteomyelitis
• tuberculosis
• pelvic and abdominal infections: pelvic abscess, pelvic inflammatory disease, prostatitis
Childhood disorders:
• DDH
• Perthes’ disease
• slipped femoral epiphysis
• transient synovitis (irritable hip)
• juvenile chronic arthritis
Fractures:
• stress fractures femoral neck

• subcapital fractures
• sacrum
• pubic rami
Avascular necrosis femoral head
Femoroacetabular impingement (e.g. exostoses)
Torn acetabular labrum
Sacroiliac joint disorders
Inguinal or femoral hernia
Bursitis or tendonitis:
• greater trochanteric pain syndrome

• ischial bursitis
• iliopsoas bursitis
Osteitis pubis
Neurogenic claudication
Chilblains
Rarities:
• haemarthrosis (e.g. haemophilia)

• Paget disease
• nerve entrapments: sciatica ‘hip pocket nerve’, obturator, lateral cutaneous nerve thigh
Depression
Spinal dysfunction incl. spinal stenosis

Non-organic pain may be present. Patient with arthritis may be fearful of being crippled.
Key history
Pain analysis, especially exact site and pain radiation. Associated symptoms such as limp,
stiffness, night pain, fever. Past history, family history, obstetric history, drug history.
Key examination
• The traditional method of look, feel, move, measure, test function and look elsewhere
• The patient should be stripped to the underwear to allow maximal exposure
• Also examine lumbosacral spine, sacroiliac joints, groin and knee
Key investigations
• Serological tests: RA factor
• FBE, ESR/CRP
• Radiological tests: plain X-ray (AP) of pelvis to show both hip joints; lateral X-ray
(‘frog’ lateral best in children)
• CT or MRI of hip joint
• Needle aspiration of joint if septic arthritis suspected
Diagnostic tips
• True hip pain is felt in the groin, thigh and medial aspect of the knee.
• Disorders of the hip joint commonly refer pain to the knee and thigh.
• Limp has an inseparable relationship with painful hip and buttock conditions.
• Keep in mind the greater trochanteric pain syndrome, especially when middle-aged
women complain of hip pain.
Hirsutism in women
Constitutional (physiological or familial)
Polycystic ovary syndrome (PCOS)

Cancer/tumour:
• virilising ovarian tumour

• adrenal tumours (cancer and adenoma)
• ectopic (paraneoplastic) hormone production (e.g. lung cancer, carcinoid)

Postmenopausal
Rarities:
• porphyria cutanea tarda

• congenital adrenal hyperplasia
Drugs (many incl. phenytoin, danazol, minoxidil, anabolic steroids, cyclosporin, corticosteroids,
OCP, phenothiazines, interferon 〈, penicillamine)
Thyroid/other endocrine (prolactinaemia, Cushing, acromegaly, hypothyroidism)

Consider anorexia nervosa
Key history
History of age of onset, extent and activity of the hair. Family history and past medical history
including endocrine disorders and drugs especially those listed opposite.
Key examination
• General inspection including distribution and character of the hair growth, endocrine
abnormalities (e.g. Cushing syndrome), skin, abdomen and breasts
Key investigations
• Consider pituitary hormones (e.g. FSH, LH, ACTH, TSH, prolactin)
• Serum thyroxine, testosterone, DHEAS
• Pelvic ultrasound (?PCOS)
• Urinary porphyrins
• Imaging of pituitary and adrenal regions
Diagnostic tips
• Mild longstanding hirsutism does not require investigation.
• Keep in mind possibility of self-medication, especially in athletes (anabolic steroids).
• Red flags include sudden appearance of hirsutism/virilisation and a pelvic or abdominal
mass.
Hoarseness
Viral URTI: acute laryngitis
Non-specific irritative laryngitis (Reinke oedema)
Vocal abuse (shouting, screaming, etc.)
Smoking
Nodules and polyps of cords
Presbyphonia in elderly: ‘tired’ voice
Hypothyroidism
Acute tonsillitis

Cancer:
• larynx, lung, including recurrent laryngeal nerve palsy, oesophagus, thyroid
Imminent airway obstruction (e.g. acute epiglottis, croup)
Rare other severe infections (e.g. TB, diphtheria)
Foreign body
Motor neurone disease
Myasthenia gravis
Toxic fumes
Vocal abuse
Benign tumours of vocal cords (e.g. polyps, ‘singer’s nodules’, papillomas)
Gastro-oesophageal reflux → pharyngolaryngitis
Goitre
Dystonia
Physical trauma (e.g. post-intubation), haematoma
Fungal infections (e.g. Candida with steroid inhalation, immunocompromised)
Allergy (e.g. angioedema)
Leucoplakia
Systemic autoimmune disorders (e.g. SLE, Wegener granulomatosis)
Masquerades
Consider:
• drugs: antipsychotics, anabolic steroids

• smoking → non-specific laryngitis
• hypothyroidism, acromegaly

Consider:
• functional aphonia
• functional stridor
Key history
Note the nature and duration of the voice change. Enquire about corticosteroid inhalations,
excessive or unaccustomed voice straining, especially singing, recent surgery, possible reflux,
smoking or exposure to environmental pollutants. Elicit associated respiratory or general
symptoms such as cough and weight loss.
Key examination
• Palpate the neck for enlargement of the thyroid gland or cervical nodes
• Perform a simple oropharyngeal examination except if epiglottitis is suspected
• Check for signs of hypothyroidism, such as coarse dry hair and skin, slow pulse and
mental slowing
• Perform indirect laryngoscopy if skilled in the procedure
Key investigations
Consider:
• thyroid function tests

• chest X-ray if it is possibly due to lung carcinoma with recurrent laryngeal nerve palsy
• indirect laryngoscopy (the gag reflex may preclude this)
• a special CT scan to detect suspected neoplasia or laryngeal trauma.
Diagnostic tips
• Acute hoarseness rarely causes any diagnostic problem or concern but the chronic cases
are often cause for concern.
• Remember that intubation causes transient hoarseness.
• Consider gastro-oesophageal reflux disease in the elderly.
Insomnia
Stress and anxiety
Depression
Inappropriate sleep hygiene or lifestyle
Environmental e.g. noisy household
Drug withdrawal inc. alcohol, hypnotics
Biorhythm disruption e.g. shift work, travel

Vascular:

• Congestive cardiac failure
Tumours:
• Pharyngeal
Other:
• Pain syndromes e.g. back, arthritis, CTS, cancer

• Respiratory e.g. asthma, COPD, nasal obstruction
• Post traumatic stress disorder
• Psychosis
• Restless legs/nocturnal myoclonus
Sleep apnoea
GORD
Dementia
Menopausal symptoms
Rarities:
• Macroglossia/tonsillar hypertrophy
• Malnutrition
• Parasomnias e.g. night terrors
• Malnutrition
Depression
Diabetes
Drugs: stimulants, alcohol, beta blockers, SSRIs, steroids
Thyroid/other endocrine: hyperthyroid
Spinal dysfunction
Urinary tract infection: nocturia

Some cases are normal variant or idiopathic.

Key history
A careful history is required because some patients have unrealistic expectations about the
required amount of sleep they need or have misperceptions of how long they have slept. Explore
lifestyle factors esp. psychosocial reasons, painful conditions, drug use and abuse, appetite,
energy, sexual issues and physical factors. Examine past medical history including diabetes,
hypertension and cerebrovascular disease, as well as drug history, esp. alcohol. Check thyroid
status, esp. hyperthyroidism.
Key examination
• General features: appearance of patient, vital signs including BMI, inspection of the nasal
passages, throat and neck (goitre)
• General respiratory and cardiovascular examination
Key investigations
Nil for most cases. Others according to history and findings.
Consider:
• FBE
• ESR/CRP
• LFTs (γGT)
• TFT
• sleep studies
Diagnostic tips
Pay close attention to drugs use, esp. alcohol, caffeine, narcotics, illicit agents, SSRIs,
benzodiazepines, and esp. if desperate request for drugs.
Be aware of the effects of ageing including carpal tunnel syndrome, arthritis, prostate problems
and incontinence.
Jaundice in adults
Hepatitis A, B, C (mainly B, C)
Gallstones
Alcoholic hepatitis/cirrhosis

Malignancy:
• pancreas
• biliary tract
• hepatocellular (hepatoma)
• metastases
Infection:
• septicaemia
• ascending cholangitis
• fulminant hepatitis
• HIV/AIDS
• leptospirosis
Paracetamol overdose
Rarities:
• Wilson syndrome
• Reye syndrome
• acute fatty liver of pregnancy
Gallstones in common bile duct
Genetic disorders: Gilbert syndrome, Wilson syndrome, galactosaemia, others
Cardiac failure
Primary biliary cirrhosis
Autoimmune chronic active hepatitis
Primary sclerosing cholangitis
Chronic viral hepatitis
Amyloidosis
Haemochromatosis
Viral infections (e.g. CMV, EBV)
Drugs (several, see list)
Anaemia (haemolytic)

Not usually applicable.
Key history
Associated symptoms (e.g. rash, pruritus, fever, arthralgia, weight loss). Medical history. Contact
with people with hepatitis or jaundice. Overseas travel, family history, drug history, IV drug use,
sexual history, occupational history.
Key examination
• General inspection including skin for signs of excoriation
• The abdominal examination is important with a focus on the liver and spleen
• Look for signs of chronic liver disease
• Test for hepatitis flap (asterixis) and fetor, which indicate liver failure
• Include dipstick urine testing for bilirubin and urobilinogen
Key investigations
• The main ones are the standard LFTs and viral serology for infective causes (hepatitis A,
B, C and possibly EBV)
• Consider hepatobiliary imaging, autoantibodies for autoimmune chronic active hepatitis
and primary biliary cirrhosis, tumour markers and iron studies
Diagnostic tips
• All drugs should be suspected as potential hepatotoxins.
• All patients with jaundice should be tested for hepatitis B surface antigen (HBsAg).
• Clinical jaundice manifests only when the bilirubin level exceeds 50 → mol/L.
• The most common causes of jaundice recorded in a general practice population are (in
order): viral hepatitis, gallstones, pancreatic cancer, cirrhosis, pancreatitis and drugs.
• Haemolytic anaemia leading to jaundice has multiple causes (e.g. autoimmune, malaria,
drugs, hereditary disorders, metabolic defects).
Knee pain
Ligament strains and sprains ± traumatic synovitis
Osteoarthritis
Patellofemoral syndrome
Prepatellar bursitis

Vascular disorders:
• deep venous thrombosis

• superficial thrombophlebitis
Neoplasia/cancer:
• primary in bone
• metastases
Infection:
• tuberculosis
Rheumatic fever
Acute cruciate ligament tear
Juvenile chronic arthritis

Referred pain: back or hip disease
Foreign bodies
Intra-articular loose bodies
Osteochondritis dissecans
Osteonecrosis
Synovial chondromatosis
Osgood–Schlatter disorder
Meniscal tears
Fractures around knee
Pseudogout (chondrocalcinosis)
Gout → patellar bursitis
Ruptured popliteal (Baker’s) cyst
Rarities:
• sarcoidosis
• Paget disease
• spondyloarthropathy
Depression
Diabetes
Spinal dysfunction (referred)

Psychogenic factors relevant, especially with possible injury compensation.
Key history
The history helps diagnosis, especially evaluating the nature of the injury. Define whether the
pain is acute or chronic, dull or sharp, continuous or recurring. Keep in mind age-related causes
and past history.
Key examination
The provisional diagnosis may be evident from a combination of the history and simple
inspection of the joint but the process of testing palpation, movements (active and passive) and
specific structures of the knee joint helps pinpoint the disorder.
Key investigations
Consider:
• FBE/ESR
• connective tissue antibodies
• blood culture
• plain X-ray including special views
• bone scan
• ultrasound
• arthrography: CT scan, MRI (excellent for investigating internal ‘derangement’)
• arthroscopy
• aspiration of fluid for culture or crystal examination.
Diagnostic tips
Examine the hip and lumbosacral spine if examination of the knee is normal but knee pain is the
complaint.
Acute haemarthrosis following an injury should be regarded as an anterior cruciate ligament tear
until proved otherwise.
Leg and ankle swelling
Physiological:
• dependency/gravitational
• prolonged sitting, standing, walking
• hot weather
• pregnancy
• mechanical (e.g. constricting clothing)
Chronic venous insufficiency (varicose veins)
Congestive cardiac failure
Drugs (e.g. calcium antagonists, NSAIDs)
Local trauma
Obesity

Vascular:
• deep venous thrombosis (DVT)

• inferior vena cava thrombosis
• thrombophlebitis
Infection:
• cellulitis
• tropical infections (e.g. filariasis, hookworm)
Cancer:
• obstruction from pelvic cancer

• localised malignancy
Other:
• kidney disease (e.g. nephrotic syndrome)

• liver disease (e.g. cirrhosis)
• skin allergy (e.g. angioneurotic oedema)

Idiopathic (periodic or cyclic) oedema
Protein-losing enteropathy (e.g. Crohn)
Lipoedema (fat and fluids) of legs
Lipidema (fat) of legs
Rarities:
• malnutrition
• lymphoedema: primary or secondary
Diabetes
Drugs (multiple; see list)
Thyroid/endocrine (hypothyroidism, Cushing syndrome)
Key history
Past history (esp. liver, heart, kidney disease), travel, drugs, occupation, recent trauma.
Circumstances of swelling (e.g. prolonged walking, long journey).
Key examination
• Cardiovascular, abdomen (signs of liver disease), legs including circulation, varicose
veins and evidence DVT
Key investigations
Consider:
• urinalysis (?albumin)
• FBE
• ESR/CRP
• U&E
• KFTs
• serum albumin/LFTs
• TSH
• ultrasound (DVT screen)
• CXR
• pelvic ultrasound
• other radiographs (e.g. CT scan, venogram).
Diagnostic tips
• Not all swollen legs require investigation.
• If the onset of oedema is acute (often <72 hours) suspect DVT.
• Pitting oedema is a feature of venous thrombosis or insufficiency, not lymphatic
obstruction.
• The significance of leg swelling varies according to the age group, whether it is bilateral
or unilateral and whether the onset is sudden or gradual.
• Drugs that can cause leg and ankle swelling include calcium antagonists, NSAIDs,
corticosteroids, glitazones, beta blockers.
Leg pain
Muscle cramps
Nerve root ‘sciatica’
Varicose veins
Osteoarthritis (hip, knee)
Exercise-related pain (e.g. Achilles tendonitis), muscular injury (e.g. hamstring)

Vascular:
• peripheral vascular disease

• arterial occlusion (embolism)
• thrombosis popliteal aneurysm
• deep venous thrombosis
• iliofemoral thrombophlebitis
Neoplasia/cancer:
• primary (e.g. myeloma)

• metastases (e.g. breast to femur)
Infection:
• osteomyelitis
• erysipelas/cellulitis
• lymphangitis
• gas gangrene
Osteoarthritis hip
Osgood–Schlatter disorder
Spinal canal stenosis → neurogenic claudication
Herpes zoster (early)
Greater trochanteric pain syndrome
Nerve entrapment (e.g. meralgia paraesthetica)
‘Hip pocket nerve’
Iatrogenic: injection into nerve
Sacroiliac disorders
Complex regional pain syndrome I
Rarities:
• osteoid osteoma
• polymyalgia rheumatica (isolated)
• Paget disease
• popliteal artery entrapment
• tabes dorsalis
• ruptured Baker cyst
Depression
Diabetes
Drugs (indirect)
Anaemia (indirect)
Spinal dysfunction

Quite possible. Common with work-related injuries.
Key history
Ask:
• Is the pain acute or chronic onset?

• Did it follow trauma or activity?
• Is it ‘mechanical’ (related to movement)?
• Is it postural?
• Is it related to walking?
• Is the pain arising from bone or from a joint?
Past history, especially cardiovascular, back pain, trauma history.
Key examination
• Watch the patient walk and assess the nature of any limp. Note the posture of the back
and examine the lumbar spine. Have both legs well exposed for inspection
• Palpate for local causes of pain and if no cause is evident examine the spine, blood
vessels and bone. Note the temperature of the feet and legs
• Perform a vascular examination including the peripheral pulses and veins
• Consider a neurological examination to test nerve root lesions or entrapment neuropathies
• Examine the joints, especially the hip and sacroiliac joints
Key investigations
Consider:
• FBE and ESR

• radiology: plain X-ray, knee, hip, lumbosacral spine; CT or MRI, bone scan
• electromyography
• vascular studies: arterial tree or venous system.
Diagnostic tips
• Pain that does not fluctuate in intensity with movement, activity or posture has an
inflammatory or neoplastic cause.
• Varicose veins can cause aching pain in the leg.
• Older people may present with claudication in the leg from spinal canal stenosis or
arterial obstruction or both.
• Think of the hip pocket wallet as a cause of sciatica from the buttocks down.
Leg ulcers
Venous insufficiency 52%
Arterial insufficiency 13%
Mixed arterial and venous disease 15%
Pressure sore
Trauma with chronic infection
Systemic disease esp. diabetes
Secondary to peripheral oedema

Vascular:
• Skin infarction (thrombotic ulcer)

• Vasculitis-RA, SLE, scleroderma
Infection:
• Post herpetic ulcer

• Tuberculosis
• HIV/AIDS
• Tropical ulcer
• Post cellulitis
Cancer:
• Primary-SCC, melanoma, malignant change in ulcer

• Secondary-ulcerating metastases
Other:
• Haematological e.g. sickle cell

• Chronic scarring—sun damaged skin
• Pyoderma gangrenosum

Insect and spider bites
Factitious (neurotic excoriations)
Rarities:
• Tropical infections e.g. leprosy

• Myobacterium ulcerans
Diabetes: neurotrophic
Drugs—systemic reaction
Anaemias: hereditary anaemias

Consider: Factitious ?dermatitis artefacta ?neurotic excoriation
Key history
Look for a cause: venous—previous DVT, varicose veins; peripheral arterial disease. Seek
history of systemic disease such as diabetes, inflammatory bowel disease, connective tissue esp.
RA. Check for a history of intermittent claudication or ischaemic rest pain; chronic ulcers
including sun damage; tropical residence. Include a drug history, esp. beta blockers,
corticosteroids, ergotamine, nifedipine.
Key examination
• General features: appearance of patient, vital signs esp. temperature
• Full cardiovascular assessment esp. lower limb
• Assess characteristics of the ulcer, esp. shape, edge, floor, discharge, surrounding skin,
regional lymph nodes
• Neurotip or similar for skin sensation
Key investigations
First line:
• FBE
• ESR/CRP
• blood sugar
Consider:

• duplex ultrasound
• ankle brachial index
• biopsy
• KFTs
Diagnostic tips
Be cautious of almenotic melanoma if undertaking biopsy. If the ulcer and site is painful,
consider arterial insufficiency.
Limp in children
Post trauma/intense exercise causing strain syndromes Ill-fitting shoes
Hip disorders, esp. transient synovitis
Heel disorders (12–14 years)
Developmental dysplasia hip (DDH)
Child abuse
Toddlers
Septic arthritis
Foreign body (e.g. needle in foot)
Perthes’ disorder
4–8 years
Transient synovitis
Slipped capital femoral epiphysis (SCFE)
Adolescents Avulsion injuries (e.g. ischial tuberosity)
Osteochondritis dissecans of knee
Duchenne muscular dystrophy

Acute viral infections
Appendicitis
Septic infections:
All groups • septic arthritis

• osteomyelitis
• tuberculosis
Cerebral palsy
Rheumatic fever
Tumour (e.g. osteosarcoma)
Juvenile idiopathic arthritis (oligo articular)
Juvenile rheumatoid arthritis
Spinal disorders:
• discitis
• fracture

Foreign body (e.g. in foot)
Osteochondritis (aseptic necrosis):
• femoral head: Perthes’ disorder

• knee: Osgood–Schlatter disorder
• calcaneum: Sever disorder
• navicular: Köhler disorder
Myalgia = ‘growing pains’
Overuse syndrome (esp. adolescent):
• patellar tendonopathy (jumper’s knee)

Stress fractures (e.g. tibia, femoral neck, navicular)
Key history
Ask about a history of trauma, foci of infection including the skin and any unusual
developmental problems. Trauma, sepsis, synovitis and DDH are perhaps the most common
reasons for a child to limp and refuse to walk. A painless waddling gait suggests DDH or
Perthes’ disorder.
The limp must be considered to be due to a definite organic cause. It is appropriate to focus
initially on the hip. Ask about the relationship of the limp to exercise and footwear.
Key examination
• The hip and the knee joints should be examined carefully if the source of the limp has no
specific localisation
• Get the child to walk and run on the toes and heels. Note the gait and check whether it is
antalgic (painful), hemiplegic (arm held out in a balancing action) or Trendelenburg
(classic for DDH). Look for evidence of muscle dystrophy
• Never forget to examine the soles of the feet and between the toes
Key investigations
Consider:
• FBE and ESR/CRP

• blood culture
• needle aspiration of joint
• radiological: plain X-ray, ultrasound, bone scan, CT or MRI scan.
Diagnostic tips
• Multiple fractures and epiphyseal separations in toddlers are highly suggestive of child
battering—order a skeletal survey if suspected.
• An acute limp may be due to injury, infection (osteomyelitis, septic arthritis), spinal
injuries, a fracture or an irritable hip (synovitis).
• Chronic cases include cerebral palsy, DDH, Perthes’ disorder and chronic SCFE.
• Infections of and around the hip joint are most common in infancy. Classically, the hip is
held immobile in about 30% of flexion with slight abduction and external rotation.
• Hip pathology can cause pain in the knee.
Lymphadenopathy
Localised infection e.g. tonsillitis, URTI, wound, skin
Specific viral e.g. rubella, measles, Coxsackie

Infection:
• Septicaemia
• HIV/AIDS
• Tuberculosis
• Syphilis, esp. secondary
• Toxoplasmosis
• Cytomegalovirus
Cancer:
• Cellular: lymphoma, leukaemia, myeloma

• Secondary metastatic nodes
• Myeloproliferative disorders

Sarcoidosis
Cat scratch disease
Kawasaki disease
Rarities:
• Tropical infections e.g. filariasis, plague

• Localised STIs e.g. granuloma inguinale
• Connective tissue disorders e.g. RA
Drugs e.g. sulphonamides, phenytoin
Key history
Gather patient history of upper respiratory infection, lower respiratory infection, possible Epstein
Barr infection, HIV, cytomegalovirus and other infections such as tuberculosis. Consider red
flags such as weight loss, fever, night sweats, history of cancer and increasing size of lumps or
lump. Note any response to antibiotics given for infection.
Key examination
• General features: appearance of patient, vital signs esp. temperature
• Palpate abdomen for evidence of splenomegaly and hepatomegaly
• Note the consistency of lumps: soft, firm, rubbery or hard
• Careful palpation of lymph node areas and matching the site of any lymphadenopathy
with a map of areas drained by the nodes
Key investigations
First line:
• FBE
• ESR/CRP
• CXR
• lymph node biopsy
Consider relevant serology according to suspected infection:
• Paul Bennell test

• syphilis
• HIV
Menorrhagia
Dysfunctional uterine bleeding (DUB)
esp. ovulatory
anovulatory
Fibroids
Cervical or endometrial polyps
Complications of hormone therapy
Adenomyosis/endometriosis

Disorders of pregnancy:
• abortion or miscarriage
Neoplasia/cancer:
• cervical cancer
• endometrial cancer
• oestrogen-producing ovarian tumour (cancer)
• leukaemia
• benign tumours (polyps, etc.)
Endometrial hyperplasia Infection:
• PID
• tuberculosis endometritis
Genital tract trauma
IUCD
Adenomyosis/endometriosis
Pelvic congestion syndrome
SLE
Rarities:
• endocrine disorders (e.g. thyroid, adrenal, hyperprolactinaemia)

• bleeding disorder
• liver disease
Depression (association)
Diabetes
Drugs (OCP, HRT)
Anaemia (association)
Thyroid disorder (hypothyroidism), other endocrine

Consider exaggerated perception. Note association with anxiety and depression.
Key history
This should be detailed to determine the exact amount of bleeding (e.g. number of tampons and
pads used and the degree of saturation). Follow a menstrual calendar over 3+ months. Take a
drug history, especially smoking. Questions need to be directed to rule out pregnancy or
pregnancy complications, trauma of genital tract, medical disorders (e.g. bleeding disorder,
endocrine disorders, cancer of the genital tract and complications of the OCP).
Key examination
General physical to rule out anaemia, evidence of a bleeding disorder and any stigmata of
relevant medical or endocrine disease. Specific examinations include:
• speculum examination
• Pap smear
• bimanual pelvic examination.
Key investigations
Careful selection is based on history, patient’s age, abnormal pelvic examination findings and
suspicion of disease.
Consider:
• FBE
• iron studies
• pregnancy testing
• TFTs
• coagulation screen
• SLE antibodies
• ultrasound
• hormones: LH and FSH (?ovulation).
Hysteroscopy and D&C remain the gold standard for abnormal uterine bleeding.
Diagnostic tips
• Self-reporting of heaviness of bleeding is unreliable.
• Acute ‘flooding’ most often occurs in pubertal girls prior to regular ovulation.
• Ovulatory DUB is the most common single cause.
• Peak incidence of ovulatory DUB is late 30s and 40s (35–45 years)
• Peak for anovulatory DUB is 12–16 years and 45–55 years (i.e. puberty and menopause).
Mouth conditions, bleeding and painful gums
Factitious: excessive brushing
Gingivitis/periodontal (gum) disease
Trauma: poor-fitting or partial dentures
Drugs: warfarin overdose, phenytoin

Oral cancer/benign neoplasms (e.g. epulis, SCC)
Blood dyscrasias (e.g. AML)
General coagulation defects
HIV/AIDS
Acute herpetic gingivostomatitis
Pitfalls (often missed) but uncommon

Acute necrotising ulcerative gingivitis (Vincent infection)
Autoimmune disease (e.g. lichen planus, SLE)
Hereditary haemorrhagic telangiectasia
Malabsorption
Nutritional deficiency (e.g. scurvy)
Hormonal (e.g. pregnancy)

Key clinical features
Erythematous bleeding gums are a common worldwide problem, which is almost always a
localised inflammation associated with poor dental hygiene. Systemic problems usually as part
of a bleeding diathesis need to be considered.
Acute necrotising ulcerative gingivitis (Vincent infection or trench mouth), which is caused by
anaerobic organisms, is rarely seen but is more common in undernourished or ill young adults
under stress. Haematological disorders such as coagulation defects, acute leukaemia and
agranulocytosis need to be excluded. Investigation may not be necessary but consider:
• FBE
• ESR
• wound swab
• autoimmune screen
• INR.
Consider dental referral.

Mouth conditions, sore tongue
Geographic tongue (migratory glossitis)
Atrophic glossitis
Trauma (bites, teeth, hot food/drink)
Aphthous ulceration
Herpes simplex virus (children)
Fissured tongue
Disorders not to be missed

Cancer
HIV

Anaemia: iron, vitamins B6 and B12, folate deficiency
Glossopharyngeal neuralgia
Lichen planus
Fissured tongue (rarely causes soreness)
Median rhomboid glossitis
Hand, foot, mouth infection
Behçet syndrome
Crohn disease
Coeliac disease
Depression
Diabetes (Candida)
Drugs (mouthwashes, aspirin)
Anaemia (various)

Possible with glossodynia.

Enquire about trauma, dental problems, nutrition, drugs and associated general symptoms. The
cause is usually obvious upon examination but there are some obscure cancers. The causes are
similar to that of a sore throat or mouth. Investigation may include:
• FBE
• serum vitamin B12, folate and ferritin levels
• swab and biopsy of a suspicious lesion.
Diagnostic tips
• Look for evidence of trauma, especially from a sharp tooth or dentures.
• When taking a history, take note of self-medications, especially sucking aspirin, a history
of skin lesions (e.g. lichen planus) and consider underlying diabetes or other
immunosuppression.
• Any non-healing or chronic ulcer requires urgent referral.
• Glossodynia (painful tongue) characteristically presents with a burning pain on the tip of
the tongue, without physical signs.
• Consider depressive illness as an underlying cause.
• Shared care with a dental or oral medical specialist is important.
Mouth conditions, ulcers
Recurrent aphthous ulceration
Trauma (e.g. rough tooth, biting)
Acute herpes gingivostomatitis
Candidiasis

Cancer:
• SCC
• leukaemia
Agranulocytosis
HIV
Syphilitic: chancre or gumma
Tuberculosis
Aspirin burn
Inflammatory bowel disease (e.g. Crohn)
Herpes zoster virus
Glandular fever (EBV)
Lichen planus
Coxsackie virus:
• herpangina
• hand, foot and mouth disease
Immunosuppression therapy
Lupus erythematosus
Rarities:
• Behçet syndrome
• pemphigoid and pemphigus vulgaris
• erythema multiforme
• radiation mucositis
Diabetes (Candida)
Drugs (see list)
Anaemia (iron-deficiency)

Unlikely.
Key history
Take a history of trauma, skin problems, stress, dental problems, drugs, allergy and possible
infections, including herpes simplex, Candida albicans, sexually transmitted diseases and
Coxsackie virus infection. Consider an immunosuppressive disorder.
Key examination
The examination should focus on the patient’s general health, dental status, characteristics of the
ulcer, cervical lymphadenopathy and the skin in general
Key investigations
Depending on the clinical picture investigations may include:
• FBE
• ESR
• swabs for M&C
• autoantibody screen
• syphilis serology
• blood sugar
• vitamin B12 and folate levels
• biopsy.
Diagnostic tips
• Non-healing ulcers warrant biopsy to exclude squamous cell carcinoma.
• Remember to enquire about medication such as phenytoin, cytotoxics,
immunosuppressants, carbimazole.
• A blood dyscrasia may be possible.
• Consider inflammatory bowel disease and coeliac disease in your considerations.
• Aphthous ulcers are usually 3–5 mm in diameter; minor ones have an erythematous
margin.
Nail abnormalities
Fungal infection: onychomycosis
Onycholysis:
• trauma to nail bed

• trauma from biting
• trauma from habit picking
Onychogryphosis
Paronychia
Psoriasis

Melanoma
Iron deficiency: koilonychia
Liver disease: leuconychia
Endocarditis: splinter haemorrhages
Chronic kidney failure: white bands, half-and-half nail
Glomus tumour
Bowen disorder/squamous cell carcinoma

Atopic dermatitis (pitted nails)
Lichen planus
Pyogenic granuloma (usually with ingrowing toenails)
Drug effects (e.g. tetracycline)
Pseudomonas infection
Connective tissue disorders (e.g. SLE)
Arsenic (Mees stripes)

Consider onychotillomania, where patients pick and self-mutilate their nails, resulting in parallel
transverse grooves (washboard deformity or habit-tic nails).
Key history
Enquire about a history of severe stress or illness and possible onychotillomania, be it excessive
nail biting, picking or cleaning. Ask whether the hands are frequently in wet work (e.g.
dishwashing, soaps and detergents) or dirt.
Key examination
Careful examination of nails: look for associated skin disease (e.g. psoriasis, atopic dermatitis,
tinea pedis, lichen planus)
Key investigations
• Nail clippings for culture and histology
• FBE and ESR
• Consider LFTs and CXR
Diagnostic tips
• Clubbing is an abnormality of the fingertips rather than nails.
• Crumbly white nails are not always caused by fungus.
• Skin disorders that can involve nails include atopic dermatitis, psoriasis, epidermolysis
bullosa, exfoliative dermatitis and lichen planus.
Nasal drip (rhinorrhoea)
Upper respiratory tract infection esp. common cold
Rhinitis: acute infective, allergic, vasomotor
Vasomotor stimulation e.g. cold wind, smoke, irritants
Sinusitis→post-nasal drip
Senile rhinorrhoea

Vascular:
• Cluster headache
Infection:
• Chronic infective granulomas e.g. TB
Cancer/tumour:
• Malignancy: nasal fossa, sinus, nasopharynx
Other:
• CSF rhinorrhoea—post head injury

• Wegener’s granulomatosis

Nasal foreign body e.g. in toddlers
Trauma ± blood
Adenoid hypertrophy
Illicit drugs e.g. cocaine, opioids esp. heroin
Inhaled irritant gases or vapour
Rarities:
• Choanal atresia
• Barotrauma
Drugs: topical OTC→rhinitis medicamentosa; narcotics
Hypothyroidism
Key history
Elicit nature of discharge: watery, mucoid, bloody, ?offensive and volume. Is it acute or chronic,
intermittent or continuous? Associations: respiratory symptoms, nasal blockage, post-nasal drip,
headache, local pain. Check for possible influence of physical factors: wind, cold, irritants,
smoke. Also check for presence of allergic rhinitis or sinusitis. Ask if there is a possible history
of head trauma, nose problems or nasal surgery. Also take a drug history, including OTC
medications esp. sympathomimetics, illicit drugs, prescribed drugs.
Key examination
Look for cause. Inspect nose and nasal cavity with a Thudicum speculum or large auriscope.
Note the position of the septum, nature of nasal mucosa and look for polyps or other tumours.
Key investigations
Usually none required. Consider:
• micro/culture of discharge
• X-ray sinuses
• CT scan
• allergy testing
Diagnostic tips
Beware of persistent blood-stained discharge esp. if unilateral and obstruction. Clear discharge
following direct facial or head injury may represent CSF leakage from a skull fracture.
Neck lumps
Lymphadenitis (reaction to local infection)
• acute: viral or bacterial

• chronic: MAIS (atypical tuberculosis), viral (e.g. EBM, rubella)
Prominent normal lymph nodes
Goitre
Sebaceous cyst
Lipoma
Sternomastoid tumour (neonates)

Vascular:
• carotid body tumour or aneurysm
Infection:
• ‘collar stud’ abscess (atypical TB)

• tuberculosis of cervical nodes (‘King’s evil’)
• HIV/AIDS of nodes
• actinomycosis
Cancer/tumour
• lymphoma (e.g. Hodgkin)

• leukaemia
• thyroid nodule (adenoma, cancer, colloid cyst)
• metastatic nodes
• salivary gland tumours
Parotitis
Thyroglossal cyst
Lymphatic malformation ‘cystic hygroma’ (children)
Cervical rib
Rarities:
• sarcoidosis
• branchial cyst (child)
• torticollis
Key history
This depends on the age of the patient but should include in all ages a history of upper
respiratory infection, lower respiratory infection, possible Epstein–Barr, HIV, cytomegalovirus
and tuberculosis infection. Consider red flags such as weight loss, dysphagia, history of cancer
and increasing size of the lump. Note any response to antibiotics given for a throat or upper
airways infection.
Key examination
• Careful palpation of lymph nodes areas and matching the site of any lymphadenopathy
with a ‘map’ of areas drained by the nodes
• Examine the lump according to the classic rules of look, feel, move, measure, auscultate
and transilluminate
• Palpate the midline anterior area for thyroid lumps and the submental area for
submandibular swellings
• Note the consistency of the lump: soft, firm, rubbery or hard
Key investigations
• FBE
• ESR/CRP
• CXR
• TFTs (of thyroid swelling)
• Fine needle aspiration biopsy of thyroid nodules
• Lymph node biopsy
Thyroid and primary tumours: imaging techniques (if necessary to assist diagnosis) include:
• ultrasound
• axial CT scan (esp. in fat necks)
• MRI scan (distinguishes a malignant swelling from scar tissue or oedema)
• tomogram of larynx (malignancy)
• barium swallow (pharyngeal pouch)
• sialogram
• carotid angiogram.
Diagnostic tips
• The 20:40 guideline rule according to age:
o 0–20 years: congenital, inflammatory, lymphoma, TB
o 20–40 years: inflammatory, salivary, thyroid, lymphoma
o >40 years: lymphoma, metastases.
• The 80:20 rule: most neck lumps (80%) are benign in children while the reverse applies
to adults.
• Causes of neck swelling are lymph nodes (85%), goitre (8%), others (7%).
• Suspicious lymph nodes are >2.5 cm diameter especially if firm or hard and less mobile.
• Consistent rules: hard—secondary carcinoma; rubbery—lymphoma; soft—sarcoidosis or
infection; tender and multiple—infection.
Neck pain and stiffness
Vertebral dysfunction, incl. acute torticollis
Traumatic ‘strain’ or ‘sprain’, incl. ‘whiplash’
Cervical spondylosis

Cardiovascular:
• angina
• subarachnoid haemorrhage
• arterial dissection
Neoplasia/cancer:
• primary tumour
• metastasis
• Pancoast tumour
Infection:
• osteomyelitis
• meningitis
• atypical infection, e.g. tetanus, leptospirosis
Vertebral fractures or dislocation

Disc prolapse
Myelopathy
Cervical lymphadenitis
Outlet compression syndrome (e.g. cervical rib)
Ankylosing spondylitis
Oesophageal foreign bodies and tumours
Paget disease
Depression
Thyroid disorder (thyroiditis)
Spinal dysfunction

Highly probable. Stress and adverse occupational factors relevant.
Key history
General pain analysis, especially the nature of onset, its site and radiation, and associated
features. Past history of neck pain and trauma. Check for presence of radicular pain in arm and
paraesthesia or numbness, and for weakness in the arm.
Key examination
• Follow the process for examination of any joint or complex of joints: look, feel, move,
measure, test function, look elsewhere and X-ray
• Three objectives of the examination: reproduce the patient’s symptoms, identify the level
of the lesion or lesions, determine the cause (if possible)
• Perform a neurological examination if radicular pain, weakness or paraesthesia is present
in the arm
Key investigations
Consider:
• FBE
• ESR
• rheumatoid arthritis factors
• radiology can include several modalities but MRI is the investigation of choice for
radiculopathy, myelopathy, suspected spinal infection and tumours.
Imaging should be selected conservatively and plain X-ray is not indicated in the absence of red
flags and major trauma.
Diagnostic tips
• The commonest cause of neck pain is idiopathic dysfunction of the facet joints without a
history of injury.
• Strains, sprains and microfractures of the facet joints, especially after a whiplash injury,
are difficult to detect and are often overlooked as a cause of persistent pain.
• ‘One disc—one nerve root’ is a working rule for the cervical spine.
Palpitations
Anxiety
Premature beats (ectopics)—atrial and ventricular
Sinus tachycardia, e.g. fever, exercise
Supraventricular tachycardia
Drugs (e.g. stimulants)

Myocardial infarction/angina
Arrhythmias:
• atrial fibrillation or flutter

• ventricular tachycardia
• bradycardia/heart block
• sick sinus syndrome
• torsade de pointes
Long QT syndrome
Wolff–Parkinson–White (WPW) syndrome
Electrolyte disturbances:
• hypokalaemia
• hypomagnesaemia
• hypoglycaemia (type 1 diabetes)
Fever/infection
Pregnancy
Menopause
Drugs (e.g. caffeine, cocaine)
Mitral valve disease
Aortic incompetence
Hypoxia/hypercapnia
Rarities:
• tick bites (T1–5)

• phaeochromocytoma
Depression
Diabetes (indirect)
Drugs (see list)
Anaemia
Thyroid disorder, hyperthyroidism
Spinal dysfunction

Quite likely. Consider cardiac neurosis, anxiety.
Key history
Ask the patient to describe the onset and offset of the palpitations, the duration of each episode
and any associated features. Then ask the patient to tap out on the desk the rhythm and rate of the
heartbeat experienced during the ‘attack’. If the patient is unable to do this, tap out the cadence
of the various arrhythmias to find a matching beat.
An irregular tapping ‘all over the place’ suggests atrial fibrillation, while an isolated thump or
jump followed by a definite pause on a background of a regular pattern indicates premature beats
(ectopics), usually ventricular.
Take a past history and family history including caffeine intake, smoking, alcohol, social drugs
such as marijuana or cocaine, and prescribed drugs (β blockers, antipsychotics, antidepressants,
thyroxine, digoxin, nifedipine, sympathomimetic).
Key examination
• The ideal time to examine the patient is during the palpitations. If not, the examination is
usually normal
• The cardiovascular examination should assess the pulse rate, rhythm, volume and
character
• The general examination should investigate features suggestive of anaemia, anxiety,
tremors, dyspnoea and thyroid disease
• Look for evidence of mitral valve prolapse
Key investigations
A checklist includes:
• FBE
• TFTs
• serum glucose
• urea, electrolytes and magnesium
• ECG
• cardiac enzymes
• echocardiography
• Holter monitoring.
Diagnostic tips
• A relatively non-specific symptom.
• Consider hyperthyroidism as a cause of atrial fibrillation or sinus tachycardia even if the
clinical manifestations are not apparent.
• Arrhythmia of sudden onset suggests paroxysmal supraventricular tachycardia (PSVT),
atrial flutter/fibrillation or ventricular tachycardia.
• Common triggers for premature beats and PVST are smoking, anxiety and excessive
caffeine.
Paraesthesia and numbness
Diabetic peripheral neuropathy
Nutritional peripheral neuropathy esp. alcohol, B 12 , folate
Hyperventilation with anxiety
Nerve root pressure e.g. sciatica, cervical spondylosis
Nerve entrapment esp. carpal tunnel syndrome
Neurotoxic drugs

Vascular:
• CVA/TIA
Infection:
• AIDs
• Lyme disease
• Leprosy
• Some viral infections
Tumour/cancer:
• Disseminated malignancy
• Cerebral/spinal cord tumours
Other:
• CKF: uraemia
• Guillain–Barré syndrome
• Trauma to spinal cord
• Marine fish toxins e.g. toadfish, Ciguatera
Migraine variant with focal signs
Multiple sclerosis/transverse myelitis
Hypocalcaemia
Rarities:
• Chronic inflammatory polyneuropathy

• Charcot–Marie–Tooth syndrome
• Amyloidosis
• Heavy metal toxicity e.g. lead
Diabetes
Drugs e.g. cytotoxic agents, interferon (see list)
Anaemia: pernicious anaemia
Thyroid/other endocrine: hypothyroid?
Spinal dysfunction

Consider conversion reaction (hysteria), severe anxiety disorder. Some cases may be idiopathic.
Key history
Analyse symptoms: the nature, distribution, onset and associated neurological symptoms (motor,
sensory), such as vertigo, seizures, vision. Check for other associated general symptoms such as
fever, weight loss, pruritus, rash, weakness.
History of diabetes, migraine, cancer, spinal problems, injury, possible bites, fever/sweating and
other symptoms. Take a travel and diet history, incl. nutrition and alcohol. Gather a drug history,
particularly cancer therapy, interferon, colchicine, thalidomide, statins, alcohol or any illicit
drugs.
Check the patient’s occupational history, e.g. exposure to lead, and psychiatric history, esp.
anxiety states.
Key examination
• General health and nutritional status.
• Focused neurological especially sensory, motor function, reflexes.
• Look for ‘glove and stocking’ distribution, muscle wasting e.g. thenar eminence.
• Peripheral vasculature.
Key investigations
First line:
• urinalysis
• blood sugar
• FBE
• ESR/CRP
Consider:
• serum calcium
• B 12 and folate
• LFTs (γGT)
• U&E
• TFTs
• KFTs
• nerve conduction studies
According to clinical findings (refer):
• imaging e.g. spine, carotid vessels, CT or MRI, angiography

• specific blood tests for infection
• lumbar puncture (CSF protein, oligoclonol I g G, etc)
Diagnostic tips
Take a detailed drug history including the above, alcohol and OTC medications. Intermittent
perioral paraesthesia indicates hypocalcaemia associated with hyperventilation. In many cases of
peripheral neuropathy or a sensory symptoms, the diagnosis is not only elusive but may not be
identified.
Pelvic pain
Gynaecological disorders, for example:
• endometriosis
• dysmenorrhoea/mittelschmerz
• pelvic adhesions
• ovarian cyst – torsion, pressure or rupture
Musculoskeletal disorders
Referred spinal pain

Neoplasia/cancer:
• lower bowel
• cervix and uterus
• ovary
Vascular:
• internal iliac artery → claudication
Infection:
• osteomyelitis
• pelvic inflammatory disease
• pelvic abscess
Ectopic pregnancy
Strangulated hernia (femoral or inguinal)

Endometriosis
Paget disease
Stress fractures (incl. SCFE)
Prostatitis/prostatodynia
Misplaced IUCD
Hernia in evolution (e.g. inguinal)
Nerve entrapment
Rectum: proctitis or prolapse
Depression
Spinal dysfunction
UTI

Functional disorders possible. Psychosexual dysfunction. Pelvic congestion syndrome.

As it is almost always seen in women rather than men the focus will be taking a history of pain
associated with periods, ovulation and sexual intercourse. It is invariably linked at times with
lower abdominal pain (see ‘Lower abdominal pain and pelvic pain in women’).
In men it is related to trauma, sporting injuries, prostatic disorders and hernias. Examination of
the abdomen and pelvis is important, especially rectal and vaginal examinations.
Key investigations
Consider and select from:
• FBE
• ESR/CRP
• urine MC ± chlamydia PCR
• STI tests
• pregnancy test
• plain X-ray
• vaginal or pelvic ultrasound
• colour Doppler US imaging
• colonoscopy/flexible sigmoidoscopy
• laparoscopy if appropriate.
• cutaneous pain mapping
Diagnostic tips
• The incidence of chronic pelvic pain (CPP) is 15% in 18–50 year old women.
Endometriosis causes 33% and adhesions 24%.
• CCP in women is the reason for 40% of gynaecological laproscopies and 15% of
hysterectomies.
• Pelvic congestion syndrome is regarded as a type of ovarian dysfunction causing
unilateral pain, deep dyspareunia and postcoital aching.
Pruritus ani
Chronic dermatitis + ‘itch-scratch’ cycle + stress
Seborrhoeic dermatitis (esp.), eczema
Antibiotic treatment
Contact dermatitis: clothing and perfumed toiletries
Irritation from excessive moisture and faecal discharge/soiling (esp. elderly)

Crohn disease
Anorectal carcinoma
Extramammary Paget disease
Sexually transmitted infections, e.g. syphilis
Other disorders
Candidiasis
Tinea cruris
Pinworm (threadworm) (esp. children)
Psoriasis (look for fissures in natal cleft)
Overzealous hygiene (e.g. OCD)
Post-diarrhoea esp. chronic or recurrent
Local anorectal conditions (e.g. piles, fissures, fistulas, skin tags, warts)
Depression
Diabetes
Drugs (esp. antibiotics)

Psychological factors: stress and anxiety, fear of cancer.
Key history
This includes past history, especially chronic dermatoses (esp. seborrhoeic dermatitis and contact
dermatitis), diabetes, chronic diarrhoea (e.g. Crohn disease, coeliac disease) and psychological
disorders. Enquire about lifestyle factors such as excessive sweating, sports activity and habit
scratching.
Key examination
• General inspection of skin and anorectal area. Skin changes can vary from minimal signs
to marked pathology that can show linear ulceration, maceration or lichenification
• A full anorectal examination is necessary
Key investigations
• Blood glucose
• Urinalysis
• Local skin scrapings and microscopy to detect organisms
• Stool examination (for ova and parasites)
Diagnostic tips
• Pruritus ani is worse at night, during hot weather and after exercise.
• It is seen typically in adult males with considerable inner drive, often at times of stress
and in hot weather when sweating is excessive.
• In children pinworm infestation should be suspected.
Pruritus, generalised
Psychological/emotional
Old, dry skin (senile pruritus)
Atopic dermatitis (eczema)
Contact (allergic) dermatitis
Varicella (chicken pox)

Cancer:
• lymphoma/Hodgkin
• leukaemia: CLL
• multiple myeloma
• other cancer, e.g. mycosis fungoides
Scabies (severe infestation)
Chronic kidney failure
Primary biliary cirrhosis/other causes (e.g. jaundice)

Pregnancy
Tropical infection/infestation
Polycythaemia rubra vera
Polyarteritis nodosa
Lichen planus
Generalised sensitivity (e.g. fibreglass, bubble bath)
Depression
Diabetes
Drugs (several types; see list)
Anaemia (iron deficiency)
Thyroid (hyper and hypo) disorders
Spinal dysfunction (nostalgia paraesthetica)

Quite likely: consider anxiety, parasitophobia.
Key history
Enquire about nature and distribution of itching. Consider pregnancy, liver disease and
malignancy of the lymphatic system, particularly Hodgkin lymphoma. A careful review of any
drug history is important. Note any associated general symptoms such as fever.
Key examination
• General examination of the skin, abdomen and lymphopoietic systems
Key investigations
Consider:
• FBE/ESR/CRP
• urinalysis
• pregnancy test
• iron studies
• kidney function tests
• TFTs
• blood sugar
• chest X-ray
• skin biopsy
• stool examination (for ova and cysts)
• lymph node biopsy (if present)
• skin testing.
Diagnostic tips
• The itching of polycythaemia may be triggered by a hot bath and lasts for at least 1 hour.
• Pruritus can be the presenting symptom of primary biliary cirrhosis and may precede
other symptoms by 1–2 years.
• The itch of Hodgkin lymphoma (in 30%) may be unbearable.
• Drugs that can cause pruritus: aspirin, barbiturates, morphine, cocaine, penicillin, other
antibiotics, anticytotoxics.
Pruritus, localised skin
Atopic dermatitis (eczema)
Contact dermatitis (irritant and allergic)
Urticaria
Insect bites/infestations
Psoriasis
Simple pruritus (cause not found)
Other disorders
Infection/infestations:
• scabies
• pediculosis (scalp, body, pubic)
• tinea cruris
• Candida intertrigo
• bed bugs
Non-infection:
• pityriasis rosea
• lichen planus
• dermatitis herpetiformis
• asteatosis (dry skin)
• prickly heat (miliaria/heat rash)
• Grover disease
• chilblains
• seborrhoeic dermatitis (usually mild)
Consider (rare):
• myeloproliferative disorders
• cutaneous T-cell lymphoma
Depression
Diabetes
Drugs

Psychogenic including dermatitis artefacta.
Key history
Includes past history, especially chronic dermatoses (particularly atopic dermatitis and contact
dermatitis), diabetes and psychological disorders. Enquire about exposure to infestations such as
‘backpacker’ lodgings, scabies and sexual contact. Drug history is important.
Key examination
• General and localised examination of the skin
• Note any scratch marks
• Look for evidence of insects such as scabies, lice and bed bugs, the violaceous rash of
lichen planus and the vesicles of dermatitis herpetiformis
Key investigations
• FBE/ESR
• Blood sugar
• Microscopic examination of skin scrapings
• Skin biopsy
Diagnostic tips
• Pruritus is a feature of dry skin, common in the elderly.
• An intense localised itch is suggestive of scabies or bed bugs.
Purpura
Simple purpura (easy bruising syndrome)
Senile purpura
Corticosteroid-induced purpura
Immune thrombocytopenic purpura
Henoch–Schönlein purpura

Malignant disease:
• leukaemia
• myeloma
Aplastic anaemia
Myelofibrosis
Infection:
• septicaemia
• meningococcal infection
• measles
• typhoid
• dengue/chikungunya
• other tropical haemorrhagic viral infections
Disseminated intravascular coagulation
Thrombotic thrombocytopenic purpura
Fat embolism
Kidney failure

Haemophilia A, B
von Willebrand disease (vW)
Post-transfusion purpura
Trauma (e.g. domestic violence, child abuse)
Rarities:
• hereditary telangiectasia (Osler–Weber–Rendu syndrome)

• Ehlers–Danlos syndrome
• scurvy
• Fanconi syndrome
Drugs:
• chloramphenicol
• corticosteroids
• sulphonamides
• quinine/quinidine
• thiazide diuretics
• NSAIDs
• cytotoxics
• oral anticoagulants/heparin
Anaemia:
• aplastic anaemia
Psychogenic factors
Factitious purpura (intentionally pinching skin)
Key history
Include family history, drug history and features of the purpura such as post trauma or
spontaneous, recurrent episodes of bleeding and whether any bleeding is out of proportion to the
trauma.
Key examination
• Detailed examination of the skin, lips and oral mucosa, lymph node areas, abdominal
examination with emphasis on spleen and liver
• Urinalysis searching for blood (microscopic or macroscopic) is important
Key investigations
FBE and blood film
• If coagulation defect suspected:

o - prothrombin time i.e. INR
o - activated partial thromboplastin time
o - fibrinogen level
o - thrombin time.
• If platelet pathology suspected:
o - platelet count
o - platelet function analyser (PFA-100).
• If inherited disorders suspected:
o - factor VIII
o - vW factory activity
o - vW factor antigen.
Diagnostic tips
• Platelet abnormalities present as early bleeding following trauma.
• Coagulation factor deficiencies present with delayed bleeding after initial haemostasis is
achieved by normal platelets.
• A normal response to previous coagulation stresses (e.g. dental extraction, circumcision
or pregnancy) indicates an acquired problem.
• If acquired, look for evidence of MILD: malignancy, infection, liver disease and drugs.
Rectal bleeding
Haemorrhoids/perianal haematoma
Anal fissure
Colorectal polyp
Diverticulitis
Excoriated skin (anal pruritus)

Vascular:
• ischaemic colitis
• angiodysplasia (vascular ectasia)
• anticoagulant therapy
Infection:
• enteritis (e.g. Campylobacter, Salmonella)
Cancer/tumours:
• colorectal, caecum
• lymphoma
• villous adenoma
Other:
• inflammatory bowel disease (colitis/proctitis)

• intussusception

Rectal prolapse
Anal trauma (accidental/non-accidental)
Villous adenoma
Rarities:
• Meckel diverticulum
• solitary ulcer of rectum
Key history
Nature of the bleed, including fresh versus altered blood, mixed with faeces and/or mucus, in
toilet bowl or on underwear. Quantity of bleeding: slight, moderate or torrential. Associated
symptoms (e.g. weight loss, constipation, diarrhoea, pain, weakness, presence of lumps, urgency,
unsatisfied defecation, recent change of bowel habit).
Key examination
• General inspection (evidence of anaemia) and vital signs
• Abnormal examination, anal inspection, digital rectal examination, proctosigmoidoscopy
Key investigations
• FBE and ESR
• Stool M&C
• Faecal occult blood
• Colonoscopy
• Consider abdominal X-ray, CT colonography, angiography, small bowel enema
(depending on clinical findings)
Diagnostic tips
• Black, tarry (melaena) stool indicates bleeding from upper GIT: rare distal to lower
ileum.
• Frequent passage of blood and mucus indicates a rectal tumour or proctitis.
• If substantial haemorrhage, consider diverticular disease, angiodysplasia or more
proximal lesions (e.g. Meckel diverticulum, duodenal ulcers).
• New bleeding age >55 years demands colonic investigation.
• 80% of rectal tumours are within fingertip range.
• In young adults, diagnosis is likely to be haemorrhoids or a fissure.
Scrotal pain
Trauma including haematoma, haematocele
Torsion of a testicular appendage
Varicocele
Epididymitis
Post vasectomy

Vascular:
• testicular torsion
Infection:
• acute epididymo-orchitis/orchitis
• fulminating necrotising cellulitis (Fournier’s gangrene)
• psoas abscess
• tuberculosis
Cancer:
• testicular neoplasm
Other:
• strangulated inguinoscrotal hernia

• acute hydrocele
Referred pain (e.g. spine, ureteric colic, abdominal aorta)
Rarities:
• idiopathic scrotal oedema

• polyarteritis nodosa
• filariasis
Key history
Determine any pre-existing predisposing factors such as lumps or history of trauma. Check travel
history, sexual history.
Key examination
• Examine and contrast both sides of the scrotum, including the inguinal and femoral
hernial orifices, the spermatic cord, testis and epididymis
• Examine the patient standing and supine
• A painful testis should be elevated gently to determine if the pain improves
Key investigations
Useful investigations include:
• FBE
• urine analysis, microscopy and culture
• Chlamydia detection tests
• ultrasound
• technetium-99m scan.
Diagnostic tips
• Torsion of the testis is the most common cause of acute scrotal pain in infancy and
childhood.
• Think of it with lower abdominal pain and/or vomiting.
• A varicocele can cause testicular discomfort—examine the patient in the standing
position.
Red flags:
• sudden onset pain

• non-reductible hernia
• erythema of scrotum or perineum
• systemic vascular symptoms, e.g. hypotension, pallor.
Shoulder pain
Cervical spine dysfunction (referred pain)
Rotator cuff tendonopathy ± a tear
Adhesive capsulitis (glenohumeral joint)
Glenoid labral tears
Bicipital tendonopathy

Cardiovascular:
• angina
Neoplasia/cancer:
• Pancoast tumour
• primary or secondary in humerus
Infection:
• septic arthritis (especially children)

• osteomyelitis
Axillary vein thrombosis
Intra-abdominal pathology, e.g. bleeding

Cervical dysfunction
Gout/pseudogout (uncommon)
Osteoarthritis of acromioclavicular joint
Winged scapula--muscular fatigue pain
Depression
Diabetes esp. adhesive capsulitis
Drugs, e.g. steroids, anabolic steroids
Thyroid disorder (rarely)
Spinal dysfunction

Shoulder is prone to (uncommonly) psychological fixation for secondary gains, depression and
conversion reaction.
Key history
A careful history should generally indicate whether the neck or the shoulder (or both) is
responsible for the patient’s pain. Enquire about features of movement:
• stiffness and restriction

• excessive movement/instability
• weakness
• rough versus smooth.
Key examination
• Examine the cervical spine then the affected shoulder
• Follow the protocol of inspection, palpation, movement, special tests for tendonopathies
• Look for impingement and a painful arc with adduction
• Undertake resisted movements for each tendon:
o - adduction for supraspinatus
o - internal rotation for subscapularis
o - external rotation for infraspinatus
o - elbow flexion for biceps
Key investigations
Consider:
• ESR (polymyalgia rheumatica)

• rheumatoid factor and anti-CCP
• ECG (if ischaemic heart disease suspected)
• imaging according to history and examination (e.g. high resolution ultrasound).
Diagnostic tips
• Consider dysfunction of the cervical spine, especially C4--5 and C5--6 levels, as a cause
of shoulder pain.
• Modern ultrasound is the investigation of choice for painful disorders of the rotator cuff.
• An older person presenting with bilateral shoulder girdle pain has polymyalgia rheumatic
until proved otherwise.
Skin ulcers
Traumatic ulcer
Decubitus (related to trauma)
Venous insufficiency
Arterial insufficiency
Mixed venous and aterial

Vascular:
• post-thrombophlebitis
• arterial insufficiency
• skin infarction (thrombolytic ulcer)
• vasculitis:
o — rheumatoid arthritis, SLE, scleroderma
Infection:
• tropical ulcer
• tuberculosis
• Mycobacterium ulcerans
• postcellulitis
• chronic infected sinus
• AIDS
Malignant:
• squamous cell carcinoma

• Marjolin ulcer (SCC)
• basal cell carcinoma (rodent ulcer)
• malignant melanoma
• ulcerating metastases
Haematological:
• spherocytosis
Neurotrophic:
• peripheral neuropathy (e.g. diabetes)

• peripheral nerve injuries (e.g. leprosy)
Other causes:
• pyoderma gangrenosum (diagnosis of exclusion)

• insect and spider bites
Anaemia
Diabetes
Drugs (e.g. illicit drugs)

Consider artefactual ulceration, i.e. factitious.
Key history
A careful history helps determine the cause of the ulceration. Relevant history includes previous
deep venous thrombosis or pulmonary embolism, diabetes, rheumatoid arthritis, inflammatory
bowel disease, chronic skin ulcers and arterial insufficiency, including a history of intermittent
claudication and ischaemic rest pain.
A drug history is important, considering especially beta-blockers and ergotamine, which can
compromise the arterial circulation, corticosteroids, and NSAIDs, which affect healing.
Key examination
• Any ulcer should be assessed for the following characteristics: site, shape, size, edge,
floor, base, discharge, surrounding skin, regional lymph nodes
• Assess the circulation: venous and arterial
Key investigations
The following should be considered, according to the clinical findings:
• full blood count

• ESR, CRP
• random blood sugar
• rheumatoid factor tests
• duplex Doppler ultrasound
• swab for specific organisms
• biopsy, especially if SCC suspected.
Diagnostic tips
• The great majority of leg ulcers are vascular in origin due to arterial insufficiency or
venous hypertension.
• If clinical findings don’t provide the diagnosis, ordering the ankle brachial index (ABI) is
essential if pulses are not palpable to exclude arterial disease. Duplex Doppler ultrasound
is the key investigation for venous disease.
Skin, acute skin eruptions
Measles
Rubella
Erythema infectiosum (‘slapped cheek’ disease)
Roseola infantum
Other viral exanthema (e.g. enterovirus)
Hand, foot and mouth disease
Pityriasis rosea
Herpes zoster (shingles)
Drug reaction (see list)
Impetigo
Herpes simplex
Allergic rash (incl. contact dermatitis)

Vascular:
• Stevens-Johnson syndrome
• other vasculitides
Infection:
• purpura of meningococcus
• primary HIV infection
• folliculitis (e.g. pseudomonas, staphylococcus)
• secondary syphilis
• scarlet fever
Other:
• erythema nodosum

Guttate psoriasis
Epstein--Barr virus (EBV) mononucleosis
Arbovirus infection (e.g. dengue, Ross River fever,
Barmah Forest virus, Japanese encephalitis)
Scabies
Kawasaki disease
Eczema herpeticum
Zoonoses (e.g. listeriosis, Q fever)
Rarities:
• filovirus haemorrhagic diseases (e.g. Ebola, Marburg virus)

• erythema multiforme
Key history
Should be adapted to patient’s age as viral exanthema common in children. Site and mode of
onset of rash, mode of progression and past history (e.g. eczema). Constitutional disturbance
(e.g. pyrexia, pruritus). Drug history and exposure to irritants. Diet including unaccustomed
food. Herald patch (pityriasis rosea). Contact with infectious diseases including child care
centres and school. Overseas travel. Bleeding or bruising tendency.
Key examination
Skin of whole body
• Nature and distribution of the rash including lesion characteristics

• Nails and soles of feet
• Scalp, mucous membranes and oropharynx
• Conjunctivae and the lymphopoietic system (?lymphadenopathy, ?splenomegaly)
Key investigations
Many diagnoses are clinical. Consider:
• FBE/ESR/CRP
• EBV test
• HIV test
• serology for rubella, parvovirus, syphilis and other suspected infections
• viral and bacterial cultures.
Diagnostic tips
• Be vigilant for the deadly meningococcal septicaemia, which may present as an
erythematous rash initially prior to the development of purpura.
• Prescribed drugs are a common cause of rash, especially toxic erythema. Examples are
antibiotics, especially penicillin, thiazides, anti-epileptics, allopurinol, NSAIDs and other
anti-arthritic agents.
Skin, pigmented lesions
Naevi: congenital and acquired
Seborrhoeic keratoses
Solar keratoses
Freckles
Lentigines

Pigmented squamous cell carcinoma
Pigmented basal cell carcinoma
Melanoma:
• lentigo maligna
• superficial spreading melanoma
• nodular melanoma
• acral lentiginous melanoma
Other disorders
Haemangioma (thrombosed)
Dermatofibroma
Pyogenic granuloma
Foreign body granuloma
Talon noir (black heel)
Becker naevus
Common melanocytic naevi:
• congenital
• acquired
o — junctional → compound → intradermal
o — halo
o — blue
o — spitz
o — dysplastic melanocyte
Key history
Establish the history of the lesion and associated features. Family history, especially of
melanoma. Determine history of past residential (geographic) areas, sun exposure, history of
sunburn and the practice of preventive measures.
Key examination
• Systematic examination of the skin especially searching for melanoma
• Starting at the head, examine the hairline, backs of the ears, neck, back and backs of the
arms. Pull down the underwear to expose the buttocks, examine the backs of the legs and
feet. Then examine the front of the body including the anterior surfaces of the legs
• Apply the ABCDE system to a suspicious lesion: Asymmetry, Border, Colour, Diameter,
Evolution and/or Elevation
Key investigations
• Photography to monitor dysplastic naevi
• Dermoscopy
• Excision biopsy
Diagnostic tips
• Most pigmented lesions are benign but one-third of all melanomas arise in pre-existing
naevi, many of which are dysplastic.
• Melanoma is extremely rare before puberty.
Skin, vesicular rash
Herpes simplex
Herpes zoster
Hand, foot and mouth disease
Dermatitis: contact, atopic
Insect and arachnoid bites
Molluscum contagiosum
Burns

Vascular:
• Allergic vasculitis
Infection:
• Bullous impetigo (scalded skin syndrome)

• Scabies
• Anthrax
Cancer:
• Associated e.g. lymphoma, leukaemia
Other:
• Erythema multiforme
Pompholyx
Pemphigus/pemphigoid
Dermatitis herpetiformis
Fixed drug eruption e.g. sulphonamides
Trauma e.g. skin friction, thermal, acid, caustic
Rarities:
• Porphyria cutanea tarda

• Epidermolysis bullosa acquisita
Drugs e.g. penicillamine, barbiturates
Key history
Ask about recent and general health esp. any infections and associated symptoms of infectious
diseases. Check for any recent travel history or history of skin trauma, bites or stings, as well as
drug intake esp. antibiotics. Is there a family history of bullous disorders?
Key examination
General examination of skin and mucus membranes including mouth looking for hand, foot and
mouth infection and pompholyx.
Key investigations
Unlikely to be helpful.
Consider:
• FBE
• viral studies and patch testing
Sore throat
Viral pharyngitis
Epstein–Barr mononucleosis (glandular fever)
Streptococcal (GABHS) tonsillitis
Chronic sinusitis with postnasal drip
Oropharyngeal candidiasis

Cardiovascular:
• angina
Neoplasia/cancer:
• cancer of oropharynx, tongue
Blood dyscrasias (e.g. agranulocytosis, acute leukaemia)
Infection:
• acute epiglottitis (children and adults)

• peritonsillar abscess (quinsy)
• pharyngeal abscess
• diphtheria (very rare)
• HIV/AIDS

Foreign body (e.g. fish bone)
Epstein—Barr mononucleosis (glandular fever)

Candida:
• common in infants
• steroid inhalers
STIs:
• gonococcal pharyngitis
• herpes simplex (type II)
• syphilis
Irritants (e.g. cigarette smoke, chemicals)
Reflux oesophagitis → pharyngolaryngitis
Tonsilloliths
Cricopharyngeal spasm
Kawasaki disease
Chronic mouth breathing
Aphthous ulceration
Thyroiditis
Glossopharyngeal neuralgia
Rarities:
• scleroderma
• Behçet disease
• sarcoidosis
• malignant granuloma
• tuberculosis
Depression
Diabetes (Candida)
Drugs (e.g. NSAIDS, cytotoxics)
Anaemia (possible)
Thyroid disorder (thyroiditis)
Spinal dysfunction (cervical referred pain)

Unlikely, but the association with depression is significant.
Key history
First determine whether the patient has a sore throat, a deep pain in the throat or neck pain.
Enquire about relevant associated symptoms such as a metallic taste in the mouth, fever, upper
respiratory infection, postnasal drip, sinusitis, cough and other pain such as ear pain. Note
whether the patient is an asthmatic and uses a steroid inhaler or is a smoker or exposed to
environmental irritants.
Key examination
• On inspection note the general appearance, look for toxicity, the anaemic pallor of
leukaemia, the nasal stuffiness of infectious mononucleosis or the halitosis of a
streptococcal throat
• Palpate the neck for soreness and lymphadenopathy and check the sinus area
• Then inspect the oral cavity and pharynx
Key investigations
Consider:
• throat swab
• FBE
• mononucleosis test
• blood sugar
• biopsy of suspicious lesions.
Diagnostic tips
• Tonsillitis with a covering membrane may be caused by Epstein–Barr mononucleosis.
• Admit if any suspicion of epiglottitis—and do not examine the throat.
• The triad-hoarseness, pain on swallowing and referred ear pain → pharyngeal cancer.
The febrile child
Viral URTI infection incl. common cold, pharyngitis, tonsillitis
Otitis media
Acute bronchitis
Roseola
Gastroenteritis
Post immunisation

Infection:
• Bacterial
• Meningitis/encephalitis
• Septicaemia/bacteraemia
• Epiglottitis
• Pneumonia
• Oteomyelitis/septic arthritis
• Tuberculosis
• Orbital cellulitis
• Abscess
• Viral
• Epstein—Barr mononucleosis
• Exanthemata eg measles, varicella e.g. fifth disease, hand-foot-mouth disease
• Bronchiolitis/croup
• HIV/AIDS
Cancer:
• Leukaemia/lymphoma
• Neuroblastoma/sarcoma
Other:
• Acute appendicitis

Tuberculosis
Rheumatic fever
Endocarditis
Tropical infections e.g. malaria
Atypical infections e.g. zoonoses
Henoch Schonlein purpura
Kawasaki disease (persistent fever)
Heatstroke/hot car
Drugs e.g. penicillin, antihistamines

?parental ?Munchaussen by proxy
Key history
Obtain detailed account from parents of the symptoms and circumstances, esp. associations such
as vomiting, diarrhoea, sweating, cough, wheeze, headache, other pain, cognition, photophobia
and urinary symptoms. Ask about immunisation (past and recent), infectious contacts, animal
contact and travel. Past history: ?splenectomy.
Key examination
• General features: appearance of the child, interaction and level of activity, colour,
hydration, chest movement and vital signs including peripheral perfusion.
• Examine skin looking for evidence of rashes, vesicles and purpura.
• Examine the ears and throat.
• Basic neurological signs, esp. neck stiffness and fontanelles.
Key investigations (only if necessary)

First line:
• FBE/ESR
• urinalysis
• MCU
Consider:
• CXR
• blood culture
• lumbar puncture
Diagnostic tips
Fever is regarded as a temperature >38° (rectal or tympanic). Most fevers in children are caused
by viruses and are self limiting. Distinguish between focal causes, e.g. tonsillitis, and no apparent
focus when a more detailed history and examination is required. Be very mindful of septicaemia
and endocarditis.
The subfertile couple
The couple:
• ageing
• sexual technique incl. dyspareunia
Female factors approx. (40%):
• ovulation disorders e.g. ovarian failure, PCOS

• other causes amenorrhea or hypomenorrhea
• tubal disease e.g. endometriosis
Male factors (approx. 40%):
• defective sperm
• anti-sperm agents e.g. cytotoxic, anabolic steroids

Infection:
• STIs → tubal or epididymal blockage

• Pelvic inflammatory disease
• Endometrial TB
Tumours:
• Uterine fibroids/cancer
• Pituitary or adrenocortical
Other:
• Systemic illness
• Cervical stenosis
• Diet/obesity
Unreceptive cervical mucus
Rarities:
• Anatomical congenital disorders e.g. uterine, Fallopian

• Chromosomal abnormalities e.g. Klinefelter syndrome, Turner syndrome
Depression incl. drugs
Diabetes
Drugs: various
Thyroid/other endocrine: several incl. hyper/hypothyroid, prolactinaemia
Spinal dysfunction

Consider psychosexual dysfunction incl. technique
NB: unexplained 20–25%
Key history
In men: sexual function, past history incl. testicular problems e.g. mumps orchitis, undescended
testes; medical problems e.g. diabetes, STIs, genitourinary surgery; occupational e.g. exposure to
heat, pesticides; drugs e.g. chemotherapy, illicit agents, alcohol, smoking, antihypertensives.
Frequency and timing of intercourse (both). In women: past history incl. previous fertility,
obstetric, menstrual, STIs and PID, genitourinary surgery and abdominal surgery esp.
appendicitis, peritonitis, abortion, IUCD use, body weight, drugs e.g. smoking, alcohol, OCP,
anabolic steroids. Symptoms of ovulation and endometriosis
Key examination
Both: body habitus, general health, secondary sex characteristics, urinalysis.
Men: external genitalia including testes (normal range 15–35 ml) and penis, PR.
Women: genitalia and breasts, thyroid status, vaginal and pelvic examination.
Key investigations
Men:
• semen analysis
Consider:
• FSH & LH
• testosterone
• sperm function tests e.g. antibodies
• testicular ultrasound
• chromosomal analysis
Women:
• basal body temperature chart and cervical mucus diary

• s. progesterone (mid luteal)
• anti-Mullerian hormone
• rubella status
• transvaginal ultrasound
Consider:
• thyroid status
• s. prolactin
• FSH and LH
• coeliac antibodies
• chlamydia test
• hysterogram
• hysteroscopy/laparoscopy
• CT pituitary fossa
• reproductive gene screening e.g. cystic fibrosis, fragile X
Tinnitus
Ear wax or debris
Sensorineural hearing loss (esp. noise induced)
Otosclerosis
Ageing
Ear infection (e.g. viral cochleitis)
Meniere syndrome

Vascular:
• arteriovenous malformation
• carotidovenous fistula
• arterial bruits (esp. carotid)
• venous hum (jugular)
Infection:
• suppurative otitis media
Cancer/tumour:
• acoustic neuroma (unilateral)
Other:
• head injury
Impacted wisdom tooth
Temporomandibular injury/dysfunction
Alcoholism
Rarities:
• superior canal dehiscence

• glomus jugulare tumour
• syphilis
Anaemia (severe)
Depression
Drugs (aspirin, NSAIDs, loop diuretics, marijuana, quinine, aminoglycosides)
Spinal dysfunction

Consider if subjective tinnitus.
Key history
• Recent onset or longstanding
• Pulsating or non-pulsating
• Head injury
• Exposure to loud noise
• Upper respiratory infection
• Otitis externa
Key examination
• Otoscope of ear
• Cardiovascular (esp. auscultation neck)
Key investigations
• Audiogram
• Tympanogram (middle ear function)
• FBE
• MRI or CT scan (esp. if head injury)
Diagnostic tips
• Think otosclerosis in young.
• Tinnitus may precede other symptoms of Meniere syndrome by months.
• Non-pulsative and continuous → inner ear.
• Venous hum → jugular vein.
• Vascular symptoms → organic disorder.
• Stress and anxiety exacerbate tinnitus.
• Associated depression may lead to suicide.
Tiredness/chronic fatigue
Stress and anxiety
Inappropriate lifestyle and psychosocial factors
Depression
Viral/postviral infection
Sleep-related disorders (e.g. sleep apnoea)

Vascular:
• cardiac arrhythmia
• cardiomyopathy
• incipient CCF
Infection:
• hidden abscess
• HIV/AIDS
• hepatitis B and C/others
Cancer
Other:
• anaemia
‘Masked’ depression
Food intolerance
Coeliac disease
Chronic infection (e.g. Lyme disease, TB)
Fibromyalgia
Lack of fitness
Drugs: alcohol, prescribed, withdrawal
Menopause syndrome
Pregnancy
Neurological disorders:
• post-head-injury
• CVA
• Parkinson disease
Kidney failure
Metabolic (e.g. hypokalaemia, hypomagnesaemia)
Chemical exposure (e.g. occupational)
Rarities:
• Addison disease
• narcolepsy
• autoimmune disorders
Depression
Diabetes
Drugs (many)
Anaemia
Thyroid disease, other endocrine (as above)
Spinal dysfunction
UTI

Highly likely.
Key history
• Analysis of presenting complaint including associations
• General questions covering red flags, weight change, general discomfort, aches or pains,
fever, unusual lumps or bumps (lymph nodes), bleeding, rashes or pruritus, sleep patterns
including snoring, apnoea
• Symptoms review especially gastrointestinal, cardiovascular and neurological
• Drug history including self-medication, OTCs, alcohol, antianxiety, antipsychotics,
antidepressants
• Psychological: stresses, anxiety, depression, sexual problems
• Social including relationships, abuse or bullying
• Diet and exercise
Key examination
General inspection noting facial features, skin appearance and colour, hyperpigmentation,
conjunctivae
• Vital signs
• Anthropometric measurements
• Basic respiratory and cardiovascular
• Abdominal examination with focus on masses and inguinal lymphadenopathy
• Urinalysis
Key investigations
• FBE
• ESR/CRP
• Blood sugar
• Serum electrolytes, calcium, magnesium
• Kidney function tests
• Liver function tests
• Iron studies
• Faecal occult blood
• Thyroid function tests
• CXR
Diagnostic tips
• Be alert to depression including masked depression.
• Ask the patient what they believe is the cause of their tiredness.
• Be alert for the classic endocrine traps: hypothyroidism and Addison disease.
• Tiredness in absence of red flags is unlikely to have an organic cause.
• Investigations are likely to be therapeutic and reassuring rather than diagnostic.
• Learn how to undertake a brief, good physical examination and practise effective time
management.
• Do not overlook a sleep disorder.
• Believe the patient’s symptoms.
Tremor
Benign essential (familial) tremor
Senility
Physiological
Drugs: adverse effects, withdrawal
Parkinson disease (incl. drug-induced PD)
Anxiety/emotional
Alcohol

Vascular:
• cerebral infarction → Parkinsonism
Infection:
• meningoencephalitis
• tertiary syphilis
Cancer/tumour:
• cerebral tumour (frontal lobe)
Other:
• toxicity from organ failure (kidney, liver, lungs)

Cerebellar disease
Multiple sclerosis
Alzheimer dementia
Uraemia of kidney failure
CO 2 retention of respiratory failure
Hepatic failure
Rarities:
• hepatolenticular degeneration (Wilson disease)

• lesion of midbrain (red nucleus)
Drugs (withdrawal e.g. opioids, stimulants, illicit agents, benzodiazepines, caffeine, alcohol;
adverse reactions e.g. sympathomimetics, ® agonists, lithium, phenothiazines, valproate,
amiodarone; alcohol) Thyroid/other endocrine: (hyperthyroidism, hypoglycaemia,
phaeochromocytoma)

Anxiety (esp. hyperventilation), conversion disorder (‘hysteria’).
Key history
• Nature of the tremor: resting, intention, postural (action), pill-rolling, flapping (asterixis),
hysterical, mixed
• Family history of tremor
• Evidence of cognitive changes or other neurological problems
• Systems review: respiratory, cardiac, liver, kidneys
• Drug history: prescribed, OTC, illicit drugs, alcohol, caffeine
Key examination
• General appearance and vital signs
• Respiratory, cardiac, abdominal (esp. liver) and neurological examination
Key investigations
According to above:
• FBE and ESR

• thyroid function tests (?hyperthyroidism), LFTs, pulse oximetry/blood gases
• drug screen
• MRI.
Diagnostic tips
• Essential tremor eased by a small quantity of alcohol.
• Triad of essential tremor: postural or action tremor, head tremor, positive family history.
• Look for Parkinson tetrad: resting tremor, bradykinesia, rigidity, postural instability.
• Look for cerebellar tetrad: intention tremor, dysarthria, nystagmus, ataxic gait.
• Typical drugs that induce Parkinsonism are phenothiazine, butyrophenones, reserpine.
Urinary incontinence
Stress incontinence
Cystitis
Overactive bladder (detrusor instability)
Outflow obstruction e.g. prostatism
Post pelvic surgery
Enuresis

Infection:
• Prostatitis
• Chronic UTI
Cancer/tumour:
• Bladder
Other:
• Dementia
• Fistula
• Ectopic urethra
Neurogenic: multiple sclerosis, neuropathy, others
Interstitial cystitis (women)
Rarities:
• Bladder calculus
• Post pelvic fracture
Diabetes: polyuria
Drugs (see list in history)
Endocrine: diabetes insipidus
Spinal dysfunction incl. cauda equina lesion

Functional (?psychogenic)
Key history
Focus on the duration and patterns of voiding, bowel function, drug use, obstetric and pelvic
surgery history. A voiding diary is helpful to pinpoint the cause. Use of a severity index
questionnaire is very helpful. Obstructive symptoms in men with detrusor overactivity. Consider
a sleep related problem. Check drug history: diuretics, alcohol, sedatives, antidepressants, α-
adrenergic blockers e.g. prazosin, caffeine, psychoactive agents, anticholinergics, calcium
channel blockers e.g. nifedipine.
Key examination
Based on neurological, pelvic and rectal examinations
Key investigations
First line:
• urinalysis
• MSU
• KFTs
Consider (based on specialist referral):
• cystoscopy
• cystometry
• urodynamic studies
• selective imaging e.g. ultrasound, micturating cystourethrogram, IVU
Diagnostic tips
Classify incontinence into the main categories: stress, urge and continuous (overflow).
Vaginal discharge
Normal or excessive physiological discharge
Vaginitis:
• bacterial vaginosis (40–50%)

• candidiasis (20–30%)
• Trichomonas (10–20%)

Neoplasia:
• cancer (cervix, uterus, vagina)

• fistulas
STIs/PID (i.e. cervicitis):
• gonorrhoea
• Chlamydia
• herpes simplex—types 1 and 2
Sexual abuse, esp. children
Tampon toxic shock syndrome (staphylococcal infection)
Streptococcal vaginosis (in pregnancy)

Chemical vaginitis (e.g. perfumes)
Retained foreign objects (e.g. tampons, IUCD)
Endometriosis (brownish discharge)
Ectopic pregnancy (‘prune juice’ discharge)
Poor toilet hygiene
Pelvic fistula
Genital herpes (possible)
Cervical polyp
Bartholinitis
Atrophic vaginitis
Threadworms
Latex allergy (e.g. condoms)
Diabetes
Drugs
UTI (association)

Needs careful consideration; possible sexual dysfunction.
Key history
The history should include:
• nature of discharge: colour, odour, quantity, relation to menstrual cycle, associated

symptoms
• exact nature and location of irritation
• sexual history: arousal, previous STIs, number of partners and any presence of irritation
or discharge in them
• use of chemicals, such as soaps, deodorants, pessaries and douches
• pregnancy possibility
• drug therapy
• associated medical conditions (e.g. diabetes).
Key examination
• Inspection with good light includes viewing the vulva, introitus, urethra, vagina and
cervix
• Look for the discharge and specific problems such as polyps, warts, ectropion, prolapses
and fistulas
• Full pelvic examination in a postmenopausal woman
Key investigations
• pH test with paper of range 4–6
• Amine or ‘whiff’ test
• Wet film microscopy of a drop of vaginal secretions
• Full STI workup including high vaginal swab
Diagnostic tips
• Vaginal discharge is an uncommon symptom before puberty.
• It is common to overlook the problems caused by hygienic preparations including
deodorant soaps and sprays and contraceptive agents especially spermicidal creams.
Vomiting
All ages: acute gastroenteritis, motion sickness, drugs, various infections
Neonates: feeding problems
Children: viral infections/fever, otitis media, UTI
Adults: gastritis, alcohol intoxication, pregnancy, migraine

Bowel obstruction:
• oesophageal atresia (neonates)

• pyloric obstruction <3 months
• intestinal malrotation
• intussusception
• malignancy (e.g. oesophagus, stomach)
Infection:
• botulinum poisoning
• septicaemia
• meningitis/encephalitis
• others (e.g. acute viral hepatitis)
Malignancy
Intracranial disorders: malignancy, cerebellar
haemorrhage, PICA infarction
Acute appendicitis
Acute pancreatitis
Acute myocardial infarction (e.g. painless)

Pitfalls (mainly adults)
Pregnancy (early)
Organ failure: liver, kidney (uraemia), heart, respiratory
Labyrinthine disorders: Meniere syndrome, labyrinthitis
Poisoning: food, chemicals
Gut motility disorders: achalasia
Paralytic ileus
Substance abuse (e.g. opioids, ecstasy)
Radiation therapy
Hypercalcaemia
Functional obstruction: diabetic gastroparesis, idiopathic gastroparesis
Depression (possible)
Diabetes (ketoacidosis)
Drugs (multiple)
Anaemia (possible)
Thyroid and other endocrine disorders (Addison disease)
UTI esp. pyelonephritis

Possibly: extreme stress and anxiety (e.g. panic attacks). Consider bulimia (self-induced
vomiting) and functional (psychogenic).
Key history
Nausea and vomiting have a wide range of potential causes emanating from every body system.
A careful history is essential with an emphasis on drug intake, possible psychogenic factors
including self-induced emesis, weight loss, other GIT symptoms or symptoms suggestive of
systemic disease.
Key examination
• If fever is present possible sources of infections (e.g. middle ear, urinary tract and
meninges) should be checked
• A careful abdominal examination is appropriate in most instances, searching for scars
indicative of previous surgery
• Consider a neurological examination
• Be mindful of the possibility of pregnancy
• Always assess the patient’s condition including the level of hydration
Key investigations
Look for the cause and also consider biochemical abnormalities resulting from fluid and
electrolyte loss. Consider:
• pregnancy test
• urine analysis and MC
• stool MC
• endoscopy
• drug toxicity studies
• blood glucose
• radiology of GIT.
Diagnostic tips
The common cause of acute nausea and vomiting in most age groups is gastroenteritis.
• Drug ingestion is a common cause of nausea and vomiting so check for prescribed drugs
and illicit street drugs such as heroin and ecstasy.
Vulvar discomfort and irritation
Atopic dermatitis/seborrhoeic dermatitis
Chronic vulvovaginal candidiasis
Irritant contact dermatitis (e.g. douches, bubble baths)
Allergic contact dermatitis (e.g. perfumes, topical antimicrobials)
Fissuring from the above dermatoses
Trauma: ‘dry’ coitus

Cancer:
• squamous cell carcinoma

• lymphomas, etc. → pruritus
• melanoma
Infection:
• streptococcal vulvovaginitis
• herpes simplex virus; herpes zoster
Other:
• vulval vestibular syndrome (provoked vestibulodynia)

Lichen sclerosus
Urinary incontinence → ammoniacal vulvitis
Faecal soiling
Tinea cruris
Trichomonal vaginitis
Atrophic vaginitis
Aphthous ulcers
Dysaesthetic vulvodynia
Psoriasis
Lichen planus
Infestations:
• threadworms
• pubic lice
• scabies
Depression
Diabetes
Drugs (e.g. antibiotics)
Spinal dysfunction (?dysaesthesia)
UTI

Common: psychosexual problems.
Key history
• Appropriate history including atopic skin diseases.
• Gynae-urological history (e.g. oestrogen status, faecal or urinary incontinence, vaginal
discharge, ‘thrush’)
• Check allergens and irritants (e.g. panty liners, soap, bubble bath, perfumes, condoms,
douches)
• Sporting activity (e.g. bike riding and costumes)
• Check psychosexual history (e.g. dyspareunia, partnership issues, depression)
Key examination
• General health
• Inspection of vulva and rest of skin, scalp nails
• Vaginal examination
Key investigations
• Vaginal swab
• Pap smear
• Consider need for vulval biopsy and patch testing
Diagnostic tips
• The previously named vulvar vestibular syndrome or vestibulitis is now termed provoked
vestibulodynia, whereby a vestibule tender to pinpoint pressure and variable erthythema
is found, typically, in young nulliparous women.
• Always biopsy a focal lesion on the vulva.
Weight gain
Exogenous obesity
Alcohol excess
Fluid/oedema
Drugs
Genetic polymorphisms

Cardiovascular:
• cardiac failure
Hypothalamic disorders (hyperphagia):
• craniopharyngiomas
• optic gliomas
Insulinoma
Liver failure
Nephrotic syndrome
Pregnancy (early)
Postmenopause
Endocrine disorders:
• hypothyroidism
• insulinoma
• acromegaly
• hypogonadism
• polycystic ovarian disease
Idiopathic oedema syndrome
Klinefelter syndrome
Congenital disorders:
• Prader–Willi syndrome
• Laurence–Moon–Biedl syndrome
Depression
Drugs (e.g. OCP, steroids, pizotifen, sulphonylureas, insulin)
Thyroid disorder (hypothyroidism) and other endocrine (as above)

Yes: the reasons for obesity should be explored.
Key history
Ascertain food and beverage intake including typical daily meals. Exercise, drug, psychological
and family history.
Key examination
• Measure body weight and height and calculate BMI, waist circumference, waist–hip
circumference, upper arm circumference
• Assess the degree and distribution of body fat and the overall nutritional status
• Search for evidence of diabetes, atherosclerosis, hypothyroidism, Cushing syndrome and
signs of alcohol abuse
Key investigations
These are more appropriate if patient unwell:
• anthropometric measurements as above, especially BMI and waist circumference

• FBE
• blood lipids
• glucose (fasting)
• LFTs
• U&E
Consider TFTs, serum cortisol, ECG and CXR.
Diagnostic tips
• The onset of obesity can occur at any age.
• Abdominal obesity gives a higher cardiovascular risk at any rate.
• Ask the patient what they believe is the cause of their weight gain/obesity.
Weight loss
Stress and anxiety (e.g. redundancy, divorce)
Depressive illness
Non-coping elderly/dementia
Eating disorders: anorexia nervosa/bulimia nervosa

Chronic heart failure
Malignant disease, including especially:
• stomach
• pancreas
• lung
• myeloma
• caecum
• lymphoma
Infection:
• HIV infections (AIDS, AIRC)

• tuberculosis
• hidden abscess
• brucellosis
• others e.g. overseas acquired infection
Drug dependence (esp. alcohol)
Malabsorption states:
• ?intestinal parasites/infestations
• coeliac disease
Other GIT problems (e.g. inflammatory bowel disease)
Chronic kidney and hepatic failures
Connective tissue disorders (e.g. SLE, RA)
Dementia
Rarities:
• malnutrition
• Addison disease
• hypopituitarism
Depression
Diabetes
Drugs: adverse effects/substance abuse (see list)
Anaemia
Thyroid disorder (hyperthyroidism, Addison disease)
UTI

A possibility. Consider stress, anxiety and depression. Anorexia nervosa and bulimia are special
considerations.
Key history
Document the weight loss carefully and evaluate the patient’s recordings. Determine food intake
and obtain the help of an independent witness such as a spouse or parent (if possible). Food
intake may be reduced with psychogenic disorders and cancer but increased with endocrine
disorders such as diabetes and hyperthyroidism, and with steatorrhoea.
Document drug history.
Key examination
Consider:
• vital parameters (e.g. BMI, pulse, BP, temperature, urine analysis (dipstick))
• thyroid and signs of hyperthyroidism
• abdominal examination (e.g. organomegaly, masses)
• rectal examination
• look for acid dental erosion on surface upper teeth (bulimia).
Key investigations
Consider:
• FBE
• ESR/CRP
• thyroid function tests
• U&E
• HIV
• blood sugar
• faecal occult blood
• CXR
• endoscopy upper GIT
• specific imaging (e.g. CT scan abdomen).
Diagnostic tips
Any loss of more than 5% of body weight is significant.
• The most common cause in adults of recent weight loss is stress and anxiety.
• Two conditions commonly associated with weight loss are anaemia and fever; they must
be excluded.
• Ask patients what they believe is the cause of their weight loss.
• An anxiety state and hyperthyroidism can be difficult to differentiate clinically.
• Drug use causing weight loss includes opioids, amphetamines, alcohol, laxatives,
digoxin, cytotoxics, NSAIDs, theophylline.

Murtagh's Diagnostic Strategies

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Murtagh's Diagnostic Strategies

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Murtagh's Diagnostic Strategies

Abdominal pain in women

Serious disorders not to be missed

• internal iliac claudication

Neoplasms including cancer

Pitfalls (often missed)

Torsion of ovary or pedunculated fibroid

Referred pain (to pelvis):

Spinal dysfunction (referred pain)

Is the patient trying to tell me something?

• IUCD (salpingitis, ectopic pregnancy)

Abdominal pain, acute in adults

Irritable bowel syndrome

Biliary colic/renal colic

Serious disorders not to be missed

• myocardial infarction (esp. inferior)

• of bowel with large or small bowel obstruction

Pitfalls (often missed)

Myofascial tear/muscle wall pain

Faecal impaction (elderly)

Inflammatory bowel disease

Drugs (e.g. NSAIDS, iron tablets, narcotics, cytotoxics)

Anaemia (sickle cell)

Spinal dysfunction (referred)

UTI (inc. urosepsis)

Is the patient trying to tell me something?

Abdominal pain, acute in children

Gastroenteritis (all ages)

Serious disorders not to be missed

• acute appendicitis (mainly 5–15 years)

• colon cancer (rare)

• intussusception (peaks at 6–9 months)

Pitfalls (often missed)

Adnexal disorders in females (e.g. ovarian)

Abdominal pain, chronic or recurrent in

Serious disorders not to be missed

• mesenteric artery ischaemia

Pitfalls (often missed)

Biliary disease: gallstones, sludge

Lactase deficiency (i.e. lactose intolerance)

Inflammatory bowel disease

Subacute obstruction (cancer, adhesions, etc.)

• tropical infections (e.g. hydatids, melioidosis, strongyloides)

Abdominal pain, recurrent in children

Recurrent viral illness (mesenteric adenitis)

Serious disorders not to be missed

• recurrent urinary infection/ureteric reflux

• colon cancer (rare)

Pitfalls (often missed)

Childhood migraine equivalent (periodic syndrome)

Food allergy (incl. lactose intolerance)

Is the patient trying to tell me something?

Abdominal swelling (generalised)

Constipation, esp. chronic

Irritable bowel syndrome

Fibroid uterus/ovarian tumour/cyst

Serious disorders not to be missed

• ovary, stomach, colon, other

• ascites (several causes)

• chronic idiopathic pseudo-obstruction