DDX & Ix Guide For Common Symptoms in Primary Care KEC 2010 PDF

Differential Diagnosis and Investigation Guide for
Common Symptoms and Signs in Primary Care
Dr. Chan Pang Fai

MBBS, FHKCFP, FRACGP, Di
DipMed, FHKAM, MOM
Associate Consultant
Dr. Lai Kit Ping Loretta
MBBS, DCH, DFM, FHKCFP, FRACGP, DPD,
DPD, MFM,
MFM, FHKAM
FHKAM
Resident Specialist
Department of Family Medicine and Primary Health Care
Kowloon East Cluster
Hospital Authority
May 2010
2010
Content
1) Abdominal pain 1-4
2) Amenorrhoea and Oligomenorrhoea 5-6
3) Ankle edema 7-8
4) Anxiety 9-10
5) Blackout and syncope 11-12
6) Bruising 13-14
7) Change in bowel habit 15-17
8) Chest pain 18-22
9) Chronic cough 23-25
10) Constipation 26-28
11) Diarrhoea 29-31
12) Dizziness and vertigo 32-35
13) Dysmenorrhoea 36-37
14) Dyspepsia (Indigestion) 38-40
15) Dysuria 41-44
16) Epistaxis 45-46
17) Foot, ankle and heel pain 47-51
18) Galactorrhoea 52-54
19) Gynaecomastia 55-56
20) Haematuria 57-61
21) Haemoptysis 62-63
22) Haemospermia/Haematospermia 64-66
23) Hair loss 67-68
24) Headache 69-72
25) Heart murmur 73-75
26) Hip, buttock and groin pain 76-78
27) Hirsutism and hypertrichosis 79-81
28) Impotence (Erectile dysfunction) 82
29) Jaundice 83-87
30) Knee pain 88-92
31) Loin pain 93-94
32) Low back pain 95-100
33) Lower urinary tract symptoms in men 101-102
34) Lower urinary tract symptoms in women 103-104
35) Lymphadenopathy 105-109
36) Malaise/Tiredness/Fatigue 110-112
37) Mastalgia 113-114
38) Memory loss/Suspected dementia 115-119
39) Menorrhagia/Irregular menses/Abnormal uterine bleeding 120-125
40) Monoarticular joint pain 126-129
41) Multiple/polyarticular joints pain 130-134
42) Nausea and vomiting 135-139
43) Neck pain 140-143
44) Nipple discharge 144
45) Palpitation 145-148
46) Penile discharge 149-150
47) Pruritus 151-154
48) Pyrexia of unknown origin/Fever of undetermined origin 155-160
49) Raynaud’s phenomenon 161-163
50) Rectal bleeding 164-168
51) Scrotal pain 169-171
52) Shortness of breath/Dyspnoea 172-176
53) Shoulder pain 177-180
54) Subfertility/Infertility 181-184
55) Tinnitus 185-187
56) Traveller’s fever 188-190
57) Urethral discharge 191-192
58) Urinary frequency 193-194
59) Urinary incontinence 195-197
60) Vaginal discharge 198-199
61) Weight gain 200-202
62) Weight loss 203-206
63) Wrist and hand pain 207-212
Dr. Chan Pang Fai
MBBS, FHKCFP, FRACGP, DipMed, FHKAM, MOM
DR. Lai Kit Ping Loretta
MBBS, DCH, DFM, FHKCFP, FRACGP, DPD, MFM, FHKAM
1) Abdominal pain
Chronic or recurrent abdominal pain
 No discoverable causes (functional dyspepsia, postprandial distress syndrome,
epigastric pain syndrome) (50%), 28% having psychiatric diagnoses and 6%
spastic colon
Differential diagnosis
Muscle strains (16%)
Irritable bowel syndrome (12%)
Gynaecological causes including Mittelschmerz/dysmenorrhoea and PID (8%)
Peptic ulcers, gastritis and hiatus hernia (8%)
Serious disorders not to be missed: mesenteric artery ischaemia, AAA, CA
bowel/stomach/pancreas/ovaries, hepatitis, referred pain from heart and lung
Often missed: food allergies, lactase deficiency, constipation, chronic pancreatitis,
Crohn’s disease, endometriosis, diverticulitis, ureteric colic
Rarities: uraemia, lead poisoning, Crohn’s disease, porphyria, sickle cell anaemia,
hypercalcaemia, Addison’s disease
Depression
Drugs (alcohol, antibiotics, aspirin, corticosteroids, cytotoxic agents, TCAs, iron,
nicotine, NSAIDS/COX-2, sodium valproate, phenytoin)
Spinal dysfunction
UTI
Red flags for organic disease

Older patient
Nocturnal pain or diarrhoea
Progressive symptoms
Rectal bleeding
Fever
Anaemia
Weight loss
Abdominal mass
Faecal incontinence or urgency (recent onset)
Differential Diagnosis and Investigation Guide for Common Symptoms and Signs in Primary Care 1
Dr. Chan Pang Fai
Investigations
CBP: anaemia with chronic blood loss (peptic ulcer, carcinoma, oesophagitis),
elevated WBC for infective/inflammatory causes
ESR: raised with carcinoma, Crohn’s disease, abscesses, but non-specific
CRP: for infective/inflammatory causes
Liver function test: hepatobiliary disorder
Renal function test: renal stones
Amylase/lipase: pancreatitis
Urinalysis: RBC (stone, UTI), WBC (UTI), bile pigments (gall bladder or liver disease)
FOB: CA colon, diverticulitis, Crohn’s disease, ulcerative colitis
AXR and KUB: renal stones (70% opaque), biliary stones (10-30% opaque), calcified
aneurysm
CXR: lung diseases
USG: hepatobiliary system (gallstones), kidneys (renal stones), female pelvis, aortic
aneurysm, carcinoma of pancreas
IVU: urinary stones
CT abdomen: pancreatitis, solid organ disease (liver, spleen, kidney), AAA
ECG: cardiac causes
Upper endoscopy: upper GI causes, indications: signs of gastrointestinal bleeding or
anaemia, weight loss, vomiting, progression of symptoms, dysphagia, odynophagia,
previous gastric surgery, family history of gastrointestinal carcinoma, over 55 years
old (referral for endoscopy should be considered in Asians at a younger age (<45yrs
old) who present with new persistent dyspeptic symptoms as Asians are at higher risk
of gastric malignancy)
Barium meal: a barium meal may be an alternative if OGD is unavailable but his has
inferior specificity and sensitivity for the detection of structural causes of epigastric
pain and does not yield any tissue samples for further examination.
Urea breath test (UBT): diagnostic accuracy >95%, mainstay of H. pylori diagnostics if
the patient does not require on endoscopy
Serology test for H. Pylori: low diagnostic accuracy 80-84%, positive serology results
at least need to be confirmed by other methods, serology can remain positive for
months to years after successful eradication; negative predictive value is excellent
and a negative result almost rules out current infection
Stool antigen test: sensitivity 91%, specificity 93%, sensitive to room temperature,
useful in children who are unable to perform a UBT
Sigmoidoscopy and colonoscopy: lower GI causes
Dr. Chan Pang Fai
Proven indications for the diagnosis and treatment of H. Pylori:
 Peptic ulcer disease (active or confirmed history)
 A test and treat strategy is appropriate for patients with uninvestigated
dyspepsia who are <45 years of age and who do not have any ‘alarm features’
 Low grade gastric MALT lymphoma
 After endoscopic resection of early gastric cancer
 First degree relatives of patients with gastric cancer
Conditions where evidence is inconclusive for diagnosis and treatment of H. Pylori

 Investigated non-ulcer dyspepsia (i.e. ‘functional dyspepsia’: dyspepsia patients
who have no ulcer at endoscopy)
 With NSAID use
 Gastro-oesophageal reflux disease
 Population at higher risk for gastric (Japan and parts of China)
 Unexplained iron deficiency anaemia in adults
 Idiopathic thrombocytopenic purpura
References:
John Murtagh’s General Practice 4th edition
Australian Family Physician Volume 37, No. 8, August 2008
Chronic or recurrent abdominal pain in children (10% of school-aged

children)
Only 5-10% of children with organic cause found
Infantile colic (1/3 of infants between 2 to 16 wks of age)
Functional constipation
Childhood migraine equivalent
Lactose intolerance
Intestinal parasites
UTI
Peptic ulcer
Child abuse
Lead poisoning
Drugs (nicotine, marijuana, cocaine, heroin)
Psychogenic cause
Coeliac disease
Dr. Chan Pang Fai
Red flags for organic disease

<5years age
Pain localized away from periumbilical area
Nocturnal pain
Dysphagia
Persistent vomiting and diarrhoea
Abnormal clinical signs: fever, weight loss, growth failure, pubertal delay, mouth
ulceration perirectal disease, abdominal mass, hepatosplenomegaly
Investigations
Urinalysis and MSU: UTI
CBP: anaemia in peptic ulcer and lead poisoning
ESR/CRP
Stool for parasites and culture
AXR (assess faecal retention), avoid if possible
USG
H. Pylori serology
References:
Australian Family Physician Volume 37, No. 8, August 2008
Dr. Chan Pang Fai
2) Amenorrhoea and Oligomenorrhoea

 Primary amenorrhoea=failure of the menses to start by 16 years of age
 Secondary amenorrhoea=absence of menses for over 6 months in a woman
who has had established menstruation
 Oligomenorrhoea=infrequent and irregular periods, where the cycles are
between 6 weeks and 6 months
Differential diagnosis for secondary amenorrhoea or oligomenorrhoea

Pregnancy
Menopause/premature ovarian failure (hypergonadotropic hypogonadism)
Polycystic ovarian syndrome (Normogonadotropic amenorrhoea, hyperandrogenic
chronic anovulation)
Emotional (stress) and psychiatric causes such as anorexia nervosa
(hypogonadotropic hypogonadism, hypothalamic amenorrhoea)
Hyperthyroidism or hypothyroidism
Hyperprolactinaemia (pituitary tumour, medications: OCPs, antipsychotics,
antidepressants, antihypertensive, H2 blockers, opiates)
Strenous exercise (hypogonadotropic hypogonadism, hypothalamic amenorrhoea)
Drugs including illicit drugs and hormonal therapy
Outflow tract obstruction (Asherman’s syndrome: intrauterine synechiae and
scarring, from curettage or infection, hysterosalpingography, hysteroscopy, or
sonohysterography can help diagnose; cervical stenosis; obstructive fibroids or
polyps)
Investigations
Pregnancy test
Prolactin
Thyroid stimulating hormone (TSH), Free T4 if TSH abnormal
Progestogen challenge test (to detect endogenous oestrogen, give
medroxyprogesterone acetate (Provera) 10mg daily for 7-10days, a withdrawal bleed
usually occurs two to seven days after the challenge, a negative test signifies an
outflow tract abnormality or inadequate oestrogenization, an negative
oestrogen/progestogen challenge test (conjugated equine oestrogen (Premarin)
1.25mg daily for 21 days) indicates an outflow tract obstruction and a positive test
indicates an abnormality within the hypothalamic-pituitary axis or the ovaries
Gonadotropin levels: elevated follicle-stimulating hormone (FSH) or luteinizing
Dr. Chan Pang Fai
hormone (LH) levels suggest a pituitary or hypothalamic abnormality
(hypogonadotropic hypogonadism)
Oestradiol level
MRI of the sella turcica: for pituitary tumor
Evaluation of Secondary Amenorrhea
Recommendation from Practical General Practice:

After exclusion of pregnancy, test blood for prolactin, LH, FSH, Oestradiol and TFTs:
High FSH (> 30iu/L) and low oestradiol and under age of 45: premature ovarian
failure
LH/FSH ratio > 2.5 or LH > 10: PCOS
Prolactin > 800miu/L: pituitary adenoma, repeat and check drug history if level
between 400 and 800miu/L
References:
Practical General Practice 5th edition
Amenorrhoea: Evaluation and Treatment. American Family Physician Volume 73, No.
8, April 15, 2006.
Dr. Chan Pang Fai
3) Ankle edema
Bilateral:
Prolonged sitting
High salt intake (usually aggravating instead of causing the edema)
Drugs: calcium-channel blockers, methyldopa, atenolol, carvedilol, terazosin
Congestive heart failure
Renal diseases: renal impairment, glomerulonephritis
Liver diseases such as cirrhosis
Hypoalbuminuria from other causes
Hypothyroidism
Varicose veins and venous insufficiency
Lymphedema: e.g., Meige's lymphedema: A rare inherited condition where tissue
swelling (mainly involving the legs) occurs because of blockage of lymphatic drainage
system. Onset is after 35 years.
Pregnancy
Pre-eclampsia
Idiopathic
Unilateral:
Cellulitis
Deep vein thrombosis
Lymphedema
Varicose veins
Arthritis
Injury
Investigations
Urinalysis: proteinuria and renal diseases
RFT: renal diseases
LFT: liver diseases, hypoalbuminuria
TFT: hypothyroidism
CXR: heart failure
ECG: heart failure, DVT
Doppler USG: DVT
Dr. Chan Pang Fai
References:
Treatment of edema. American Family Physician Volume 71, No. 11, June 1, 2005.
http://www.wrongdiagnosis.com/sym/leg_swelling.htm
British national Formulary
Dr. Chan Pang Fai
4) Anxiety
Psychiatric diseases: generalized anxiety disorder, social anxiety disorder, panic
disorder, depression, obsessive-compulsive disorder, phobia, post-traumatic or acute
stress disorder, bipolar disorder, dementia, hypochondriasis, somatoform disorder
Drugs: bronchodilators, sympathomimetics such as pseudoephedrine, steroids,
antidepressants, antihypertensives, thyroxine
Substance use: alcohol, caffeine, cocaine, cannabis, amphetamines
Medical conditions:
Menopausal and premenstrual syndromes
Cardiovascular etiologies: MI, angina, arrhythmias, CAD, CHF, MVP
Respiratory etiologies: asthma, COPD, pulmonary embolism
Endocrine etiologies: hyper- or hypothyroidism, hypoglycemia ( “EXPLAIN”
causes: EX: Exogeneous drugs such as alcohol, insulin, sulphonylureas, Pituitary
insufficiency, Liver failure, Addison’s disease, Islet cell tumours (insulinoma),
Non-pancreatic neoplasms especially retroperitoneal fibrosacroma and
haemangiopericytomas), Cushing’s syndrome, pheochromocytoma
Neurological etiologies: TIA, Parkinson’s disease, epilepsy, meningitis,
neurosyphilis
Alcohol withdrawal syndrome
Drug withdrawal: benzodiazepine, barbiturate
Vitamin B6 deficiency (can present with agitation)
Lead, mercury (from contaminated fish), manganese (from industrial exposure)
intoxication
Organophosphate insecticides poisoning
Cancer
Investigations
ECG: cardiac causes, pulmonary embolism
CXR: respiratory causes, CHF
TFT: thyroid diseases
Early morning cortisol and 24hrs urine cortisol
RFT: hyperkalaemia and hyponatraemia in Addison’s disease
LFT: alcoholism
CBP: alcoholism
24hrs urine for catecholamines and VMA: phaeochromocytoma
Dr. Chan Pang Fai
EEG: epilepsy
References:
http://www.alternativementalhealth.com/articles/diamond.htm. RJ Diamond.
Psychiatric Presentations of Medical Illness. Revised 1/7/2002.
http://www.wrongdiagnosis.com/a/anxiety/causes.htm
Oxford Handbook of Clinical Medicine 7th edition
Dr. Chan Pang Fai
5) Blackout and syncope

 20 to 50% of adults experience one or more episodes during their lives. 75% of
persons older than 70 years will experience syncope at least once.
The underlying cause of syncope remains unidentified in 13 to 31% of patients even
after a thorough evaluation.
Vasovagal attacks (posture, stress, haemorrhage, micturition, cough)
Cardiovascular causes: postural hypotension, arrhythmias (complete heart block,
sick sinus syndrome, ventricular tachycardia, prolonged QT syndrome), aortic
stenosis, carotid sinus sensitivity
Neurological causes: transient ischaemic attacks, seizures, migraine, vertebrovasilar
insufficiency
Psychogenic causes: hyperventilation, anxiety, conversion reactions, depression
Drugs: Peripheral vasodilators (ARBs, TNG, hydralazine, prazosin), antiepileptics,
antihypertensives, barbiturates and benzodiazepines, phenothiazines,
phenoxybenzamine, SSRIs, TCAs, OTC anticholinergic compounds
Alcohol and other substance abuse
Anaemia
Hypoglycaemia
Metabolic/electrolyte disturbance such as hypokalaemia
Cervical spondylosis causing vertebrobasilar ischaemia
Autonomic failure
Sleep disorders: sleep apnoea, narcolepsy/cataplexy
Breath holding attacks in children
Transient global amnesia
Munchausen-by-proxy
Causes of syncope can also be categorized as follows:

Reflex mediated: vasovagal syncope, carotid sinus, situational (e.g., coughing,
sneezing, defecating, micturition, postmicturition), glossopharyngeal and trigeminal
neuralgia
Cardiac: mechanical or structural, arrhythmia
Orthostatic: primary (multiple system atrophy, pure autonomic failure, Parkinson’s
disease), secondary (volume depletion, medications, illegal drugs or alcohol, diabetes
or amyloid neuropathy)
Dr. Chan Pang Fai
Cerebrovascular: vertebrobasilar (transient ischaemic attacks), vascular steal
syndrome (subclavian steal syndrome), seizure, migraine
Investigations
CBP: anaemia, polycythaemia
FBG: diabetes, hypoglycaemia
RFT: electrolytes disturbance
ECG: ischaemic, arrhythmia (should be ordered for all patients with syncope,
abnormal ECG findings are common in patients with syncope, abnormal ECG findings
occur in about 90% of patients with cardiac-induced syncope but in only 6% of
patients with neurally mediated syncope)
Holter: arrhythmia
Echocardiogram: cardiac causes
Exercise treadmill: cardiac ischaemia, exercise-induced tachyarrhythmias, exercise-
associated and exertional syncope
Head-up tilt-table test (HUTT): neurogenic reflex-mediated syncope
X-ray C-spine: cervical spondylosis
CXR: cardiac diseases
Doppler USG: carotid artery stenosis
CT and MRI brain
EEG and video EEG
PET (Positron emission tomography) or SPET (Single photon emission computerized
tomography): localized brain dysfunction
References:
Evaluation of syncope. American Family Physician Volume 72, Number 8, October 15,
2005.
Dr. Chan Pang Fai
6) Bruising
 Purpura = petechiae + ecchymoses
 The routine screening tests for the investigation of patients with bleeding
disorders can occasionally be normal despite the presence of a severe
haemorrhagic state.
Thrombocytopenia (inherited): Fanconi syndrome, amegakaryocytic
thrombocytopenia
Thrombocytopenia (acquired): immune thrombocytopenic purpura, drug-induced
thrombocytopenia, disseminated intravascular coagulation, bone marrow
replacement of failure, thrombotic thrombocytopenia purpura, post-transfusion
purpura, splenic pooling
Functional platelet disorders (inherited): Glanzmann’s thrombasthenia,
Bernard-Soulier syndrome, storage pool deficiency
Functional platelet disorders (acquired): drug-induced, uraemia, myeloproliferative
disorders, dysproteinaemias
Clotting factor deficiency or inhibitor (inherited): haemophilia A, haemophilia B, von
Willebrand disease
Clotting factor deficiency or inhibitor (acquired): disseminated intravascular
coagulation, liver disease, vitamin K deficiency, oral anticoagulant therapy or
overdosage
Vascular disorders (inherited): hereditary haemorrhagic telangiectaxia, Marfan
syndrome, Ehlers-Danlos syndrome
Vascular disorders (acquired): purpura simplex (easy bruising syndrome), senile
purpura, Henoch-Scholein purpura, steroid purpura, scurvy
Drugs: aspirin, NSAIDs, corticosteroids, cytotoxics, oral anticoagulants,
sulphonamides, quinine/quinidine, thiazide diuretics
Malignant disorders: leukaemia, myeloma
Aplastic anaemia
Myelofibrosis
Severe infections: septicaemia, meningococcal infection, measles, typhoid
Trauma: domestic violence, child abuse
Factitial purpura
Dr. Chan Pang Fai
Investigations
CBP: platelet pathology
Peripheral blood smear: platelet pathology
PT/APTT/INR: coagulation defect
Urinalysis for RBC and protein
LFT: liver diseases and alcoholic
RFT: HSP caused nephritis
References:
Bleeding and Bruising: A Diagnostic Work-up. American Family Physician Volume 77,
Number 8, April 15, 2008.
Dr. Chan Pang Fai
7) Change in bowel habit

Diagnostic approach
 With presence of alarm symptoms (weight loss, GI bleed, anaemia, fever, or
frequent nocturnal symptoms, family history of cancer of colon, breast, ovary or
uterus or inflammatory bowel disease) and the Rome II criteria as starting
points.
 If there are no alarm symptoms and the Rome II criteria are not met, it is
acceptable to reevaluate the patient for persistent symptoms at a later date.
 If there are no alarm symptoms and the Rome II criteria are met, the patient can
be evaluated based on age at presentation.
 Patients aged 50 years or younger can be evaluated based on predominant
symptoms: constipation, diarrhoea, or abdominal pain.
 Patients with constipation-predominant symptoms should have a CBP, TSH,
electrolyte levels, and examination with flexible sigmoidoscopy.
 Patients with diarrhoea-predominant symptoms should have a CBP, ESR, TSH
and electrolyte levels, and flexible sigmoidoscopy.
 Patients with abdominal pain-predominant symptoms should have only a CBP.
 Patients older than 50 should be fully evaluated and considered for
gastroenterology or surgery referral.
 If alarm symptoms are present, a full evaluation should be performed regardless
of the patient’s age or presence of Rome II criteria.
Irritable bowel syndrome

 50% develop symptoms before 35 years of age, 40% develop symptoms
between 35 and 50 years of age.
 Onset in elderly persons is rare.
 Rome II Diagnostic Criteria
 At least 12 weeks (not necessarily consecutive) of at least two of the
following three symptoms:
 Abdominal pain or discomfort that is:
 Relieved with defecation
 Associated with a change in frequency of stools
 Associated with a change in appearance of stools
 Supportive symptoms (from the Rome I criteria)
 Fewer than three bowel movements per week
 More than three bowel movements per day
Dr. Chan Pang Fai
 Hard or lumpy stools
 Loose (mushy) or watery stools
 Straining during a bowel movement
 Urgency
 Feeling of incomplete evacuation
 Passing mucus
 Abdominal fullness, bloating, or swelling
Diarrhoea or constipation
Food allergy or intolerance
Diverticular disease
Colorectal cancer
Medical diseases
Drugs
Diarrhoea
Inflammatory bowel diseases: Crohn’s disease or ulcerative
Food allergy or intolerance includes lactose intolerance
Infections: parasites, bacterial, viral, opportunistic
Hyperthyroidism
Colorectal cancer: adenocarcinoma, villous adenoma
Pancreatic insufficiency
Drugs: alcohol, laxatives, metformin, acarbose, colchicines, H2-blockers, statins,
actifed, aldactone, allopurinol, antibiotics, vitamin C, statins, beta-blockers, benadryl,
betaloc, bisolvon, ACEIs, NSAIDs and COX-II, folic acid, indapamide, thyroxine,
theophylline, fosamax, lamisil, levodopa, lopid, methyldopa, minipress, PPIs,
persantin, phenytoin, glitazones, transamin, warfarin
Diabetes
Celiac disease
Constipation
Colorectal cancer: adenocarcinoma, villous adenoma
Dr. Chan Pang Fai
Hypothyroidism
Addison’s disease
Hyperparathyroidism
Hypercalcaemia
Hypokalaemia
Intestinal pseudoobstruction: diabetes, scleroderma
Drugs: antacids, antispasmodic drugs, antidiarrhoeal drugs, antidepressants (both
TCAs and SSRIs), iron, codeine (cough mixtures containing codeine), benzodiazepines
calcium supplements, calcium-channel blockers, antiparkisonian drugs, fosamax,
diuretics that cause hypokalaemia, NSAIDs, statins, carbamazepine, psychotropics,
sympathomimetics
Investigations
CBP: anaemia caused by colorectal cancer, inflammatory bowel diseases,
malabsorption
ESR/CRP: colorectal cancer, inflammatory bowel diseases
FOB: x3, colorectal cancer
TFT: Hyperthyroidism or hypothyroidism
RFT and Ca: hyperkalaemia and hyponatraemia and hypercalcaemia, in Addison
disease, hypercalcaemia in hyperparathyroidism
LFT: malabsorption in chronic diarrhoea, hypoalbuminuria
FBG: diabetes
Stool for culture and ova and parasites
Sigmoidoscopy: diverticular disease, colorectal cancer
Colonoscopy: diverticular disease, colorectal cancer, inflammatory bowel diseases
References:
Diagnosing the Patient with Abdominal Pain and Altered Bowel Habits: Is it Irritable
Bowel Syndrome. American Family Physician Volume 67, Number 10, May 15, 2003.
Irritable Bowel Syndrome. Australian Family Physician Volume 34, Number 4, April
2005.
Oxford Handbook of Clinical Medicine 7th edition.
Dr. Chan Pang Fai
8) Chest pain
 All sudden acute chest pain is cardiac (and potentially fatal) until proven
otherwise.
 Immediate life-threatening causes of spontaneous chest pain are: myocardial
infarction and unstable angina, pulmonary emobolism, aortic dissection, tension
pneumothorax.
 The main differential diagnoses of myocardial infarction include angina, aortic
dissection, pericarditis, oesophageal reflux and spasm, and hyperventilation
with anxiety.
 The commonest causes encountered in general practice are musculoskeletal or
chest wall pain and psychogenic disorders.
 Causes of chest wall pain include costochondritis, muscular strains, dysfunction
of the sternocostal joints and dysfunction of the lower cervical spine or upper
thoracic spine, which can cause referred pain to various areas of the chest wall.
 Angina is common and must always be considered. If angina-like pain lasts
longer than 15 minutes myocardial infarction must be excluded.
 The usual triad of malignancy, myocardial ischaemia and severe infections
(pneumonia/pleurisy, pericarditis and mediastinitis) must be considered.
 Referred pain from spinal dysfunction is commonly overlooked.
 Other pitfalls include a cough fracture of a rib, herpes zoster and gastrointestinal
disorders, including oesophageal spasm, reflux and cholecystitis.
 Oesophageal problems may be clinically indistinguishable from angina.
 Mitral valve prolapsed can cause chest pain.
 Breast problems can present as chest pain.
 Chest pain in children is rarely the result of serious pathology but is an
important complaint, especially in adolescents. Most cases are of unknown
aetiology (probably psychogenic), while common causes include
musculoskeletal disorders, cough-induced pain, costochondritis, psychogenic
disturbance (includes hyperventilation) and asthma.
 Chest pain in children less than 12 years old is more likely to have a
cardiorespiratory cause, such as cough, asthma, pneumonia or heart disease,
while chest pain in adolescents is more likely to be associated with a
psychogenic disturbance.
 The elderly presenting with chest pain is most likely to have angina or
myocardial infarction. Other important disorders to consider are herpes zoster,
cough fracture of the rib, malignancy, pleurisy, pulmonary embolus and
Dr. Chan Pang Fai
gastro-oesophageal reflux.
 Patients presenting with chest pain should have an ECG evaluation for ST
segment elevation, Q waves, and conduction defects. Results should be
compared with previous tracings.
 The fundamental tests that are typically available to the GP – ECG, chest X-ray
and cardiac enzymes – should help confirm the diagnosis in most instances.
 ECG may be diagnostic for ischaemic and myocardial infarction, although it may
be normal with both, including the early minutes to hours of an acute infarction.
It can be helpful to differentiate between myocardial infarction, pulmonary
embolism and pericarditis.
 Most adults with chest pain should have at least an ECG and a CXR unless the
history and physical examination suggest an obviously nonthreatening cause of
chest discomfort.
 Patients with chest pain and a negative initial cardiac evaluation should have
further testing with stress ECG, perfusion scanning or angiography depending on
their level of risk.
 Exercise stress test is the key test for defining chest pain as cardiac in origin.
Musculoskeletal (chest wall): costochondritis, Tietze’s syndrome, muscular strains,
dysfunction of the sternocostal joints
Psychogenic: depression, anxiety, panic disorder
Cardiovascular
Angina
Unstable angina
Myocardial infarction
Pulmonary embolism
Mitral valve prolapsed
Hypertrophic cardiomyopathy
Neoplasia
Carcinoma lung
Tumours of spinal cord and meninges
Severe infections
Pneumonia
Pleurisy (viral or bacterial, can also be caused by pulmonary infarction, tumour
infiltration or connective tissue disease e.g. SLE)
Mediastinitis
Dr. Chan Pang Fai
Pericarditis
Gastrointestinal
Oesophageal spasm
Gastro-oesophageal reflux
Peptic ulcer
cholecystitis
Pulmonary
Pneumothorax
Others
Herpes zoster
Fractured rib (e.g. cough fracture)
Spinal dysfunction
Bornholm disorder (pleurodynia): Coxsackie B virus infection
Cocaine inhalation
Anaemia
Da Costa’s syndrome: effort syndrome is recurrent attacks of stabbing left-sided
submammary pain, usually associated with anxiety ± depression
Breast problems
Precordial catch (Texidor’s twinge or stich in the side): common complaint,
presents as unilateral low chest pain that lasts a few seconds or minutes with
exercise such as long-distance running and relieved by straightening up and
taking very slow deep breaths followed by shallow breaths
Investigations
ECG
Exercise stress test
Exercise thallium scan: complement the exercise ECG
Ambulatory Holter monitor: for silent ischaemia, variant angina and arrhythmias
CXR: expiration film if pneumothorax is suspected
CBP: anaemia
CK: myocardial infarction
Troponin I and T: elevated in unstable angina and myocardial infarction
D-dimer: pulmonary embolism
Echocardiography: can detect abnormalities in heart wall motion when ECGs and
enzymes are not diagnostic in the early stages of myocardial infarction
Stress echocardiography: useful where standard exercise testing has been unhelpful
Transoesophageal echocardiography: for dissecting aneurysm
Dr. Chan Pang Fai
Isotope scanning: Technetium-99m pyrophosphate studies: to diagnose
posterolateral myocardial infarction in the presence of bundle branch block and
pulmonary embolism
Angiography: to evaluate coronary arteries and to diagnose pulmonary
thromboembolism
Helical CT: pulmonary embolism
Lower extremity venous USG: DVT
Oesophageal studies
Endoscopy
Barium swallow
Oesophageal manometry
Radionuclide transit studies
Spine X-ray: cervical and thoracic spines
Outpatient Diagnosis of Chest Pain
Dr. Chan Pang Fai
Wells Model for Clinical Diagnosis
of Pulmonary Embolism
Clinical finding* Points
Clinical signs and symptoms of DVT (i.e., objectively measured 3.0
leg swelling or pain with palpation of deep leg veins)
PE as likely or more likely than an alternative diagnosis 3.0
Heart rate more than 100 beats per minute 1.5
Immobilization (i.e., bedrest except for bathroom access 1.5
for at least three consecutive days) or surgery in the past
four weeks
Previous objectively diagnosed DVT or PE 1.5
Haemoptysis 1.0
Malignancy (treatment for cancer that is ongoing, within the 1.0
past six months, or palliative)
Probability
Total points Risk of PE LR+ 21

of PE (%) 21
< 2 points Low 0.13 1 to 28
2 to 6 points Moderate 1.82 28 to 40
> 6 points High 6.75 38 to 91
References
Diagnosing the Cause of Chest Pain. American Family Physician Volume 72, Number
10, November 15, 2005.
Dr. Chan Pang Fai
9) Chronic cough
 Acute cough (lasting < 3 weeks)
 Subacute cough (lasting 3 to 8 weeks)
 Chronic cough (persisting beyond 8 weeks)
 A cough that lasts longer than 3 to 4 weeks requires scrutiny
 Unexplained cough over the age of 50 is bronchial carcinoma until proved
otherwise especially if there is a history of smoking
 Chronic cough is found to have two or more causes in 18 to 62% of patients, and
three causes in up to 42% of patients
 In adults, postnasal drip syndrome, asthma, and gastroesophageal reflux disease
are the most common causes and have been referred to as a “pathogenic triad
of chronic cough.”
Smoking
Irritants: occupational and household
Post-URTI cough due to persisting bronchial inflammation and increased airway
responsiveness
Post-nasal drip
Asthma (coughing is the only manifestation of asthma up to 57% of patients)
Gastro-esophageal reflux disease (GERD) and hiatus hernia
Drugs: ACEIs (5-20% of persons), inhaled steroids, beta-blockers causing
bronchospasm
Lower respiratory tract infection: pneumonia, lung abscess, main organisms are
Haemophilus influenzae, S. pneumoniae and Moraxella
Chronic sinusitis
Chronic bronchitis, eosinophilic bronchitis
Chronic obstructive pulmonary disease (COPD)
Bronchiectasis
Pulmonary tuberculosis
Bronchogenic carcinoma, carcinoma of larynx, lymphoma
Pleurisy
Interstitial lung disorders: fibrosing alveolitis, extrinsic allergic alveolitis,
pneumoconiosis, sarcodosis
Whooping cough/pertussis
Left ventricular failure
Dr. Chan Pang Fai
Inhaled foreign body especially in children
Cystic fibrosis
Oesophageal diverticulum
Tracheo-oesophageal fistula
Habitual cough
Functional cough
Differential diagnosis (children)

Milk inhalation/reflux
Allergic rhinitis
Asthma
Recurrent viral bronchitis
Whooping cough
Croup
Foreign body inhalation
Tuberculosis
Bronchiectasis
Mycoplasma pneumonia
Smoking
Psychogenic
Cystic fibrosis
Primary ciliary dyskinesia
Tourette’s syndrome
Tracheo-oesophageal fistula
Investigations
CXR: cough lasting for > 3-4 weeks if no apparent cause is found and if cough is not
responsive to treatment to the “apparent” cause
CBP: infection, haemoptysis
ESR: infection, bronchial carcinoma
Sputum for culture: chronic infection
Sputum for AFB x3 and TB culture: haemoptysis or other TB infection symptoms
Sputum for cytology: haemoptysis or other alarming symptoms
Sputum for PCR tests for TB
Lung function tests: asthma, COPD, interstitial lung disorders
x-ray sinuses: chronic sinusitis
CT lung: bronchogenic carcinoma, bronchiectasis, interstitial lung disorders
Dr. Chan Pang Fai
Bronchoscopy: bronchial neoplasm, foreign body
Oesophageal pH monitoring and/or manometry: GERD
ECG and echocardiogarm: left ventricular hypertrophy
Evaluation of Chronic Cough
Sequential approach to the evaluation of chronic cough in the immunocompetent adult.

(ACE = angiotensin-converting enzyme; GERD = gastroesophageal reflux disease; CT =
computed tomography)
References:
Evaluation of the Patient with Chronic Cough. American Family Physician Volume 69,
Number 9, May 1, 2004.
Dr. Chan Pang Fai
10) Constipation
 Constipation is the difficult passage of small hard stools. It has also been defined
as infrequent bowel actions or a feeling of unsatisfied emptying of the bowel.
 Rome II criteria for defining chronic functional constipation in adults, infants,
and young children:
 Adults:
 Two or more of the following for at least 12 weeks in the preceding 12
months:
 Straining in more than 25% of defecations
 Lumpy and hard stools in more than 25% of defecations
 Sensation of incomplete evacuation in more than 25% of
defecations
 Manual maneuvers (e.g., digital evacuation, support of pelvic
floor) to facilitate more than 25% of defecations
 Fewer than three defecations per week
 Loose stools are not present, and there are insufficient criteria for the
diagnosis of irritable bowel syndrome
 Infants and young children
 At least two weeks of the following:
 Scybalous, pebble-like, hard stools for the majority of stools, or
firm stools two or fewer times per week
 No evidence of structural, endocrine, or metabolic disease
 Red flags for organic causes: abdominal pain, nausea, cramping, vomiting,
weight loss, maelena, rectal bleeding, rectal pain, and fever
 Red flags for organic causes in children: vomiting, sensory and motor deficits,
urinary incontinence, pigmentary abnormalities, and hair tufts in the
sacrococcygeal area, delayed growth
Adults
Idiopathic/functional constipation: simple constipation, slow transit constipation,
irritable bowel syndrome
Deficiency in dietary fibre and bad habit (Dyschezia, or lazy bowel: a rectum has
become unresponsive to faecal content, and this usually follows repeated ignoring of
calls to defecate), sedentary lifestyle
Organic disease of large bowel: carcinoma colon, diverticular disorder,
Dr. Chan Pang Fai
inflammatory bowel disease, impacted faeces, anorectal disorders (carcinoma,
fissure, haemorrhoids), adynamic bowel caused by spinal cord injury, connective
tissue disorders (scleroderma, systemic sclerosis)
Drugs: antacids, antispasmodic drugs, antidiarrhoea drugs, antidepressants (both
TCAs and SSRIs), iron, codeine (cough mixtures containing codeine), benzodiazepines
calcium supplements, calcium-channel blockers, antiparkisonian drugs (levodopa),
fosamax, diuretics that cause hypokalaemia, NSAIDs, statins, carbamazepine,
psychotropics, sympathomimetics
Endocrine/metabolic: hypothyroidism, hypercalcaemia, hyperparathyroidism,
hypokalaemia, uremia, porphyria
Neurological disease: CVA, autonomic neuropathy
Extrinsic neoplasia: lymphoma, ovary
Psychogenic: depression, anorexia nervosa, anxiety, somatization
Acquired megacolon: chronic laxative abuse, milder form of Hirschsprung’s disorder,
Chaga’s disease, systemic sclerosis
Colonic strictures: ischaemia, radiation therapy
Pregnancy
Lead poisoning
Dolichocolon
Children
Functional causes (>95%): dietary factors (inadequate dietary fiber, excessive cow’s
milk intake, dehydration, malnutrition), motility disturbance (slow transit), stool
withholding, inflammatory bowel disease
Structural abnormalities: anal disorders (imperforate anus, anteriorly displaced anus,
anal or perianal fissures, anal stenosis), colonic strictures (primary or secondary),
pelvic masses (sacral teratorma)
Endocrine, metabolic and immunologic conditions: celiac disease, cystic fibrosis,
diabetes mellitus, hypercalcaemia, hyperparathyroidism, hypokalaemia,
hypothyroidism, pregnancy, uremia, diabetes insipidus
Neurogenic conditions: cerebral palsy, hypotonia (Down syndrome, prune-belly
syndrome), spinal cord abnormalities (spina bifida, spinal tumors)
Neuromuscular conditions: aganglionosis (Hirschsprung’s disease, Chagas’ disease),
infant botulism, pseudo-obstruction syndrome
Connective tissue disorders: scleroderma, systemic lupus erythematosus
Drugs: antacids, anticholinergics, antidepressants, bismuth, laxatives, opiates,
Phenobarbital, sympathomimetics
Dr. Chan Pang Fai
Heavy metal poisoning
Gluten enteropathy
Investigations
FOB x3: colorectal cancer, inflammatory bowel disease
CBP: anaemia in colorectal cancer, inflammatory bowel disease
ESR: colorectal cancer, inflammatory bowel disease
RFT: hypokalaemia, chronic laxative abuse causing electrolyte disturbance
LFT: hypoalbuminuria in anorexia nervosa
Ca: hypercalcaemia
TFT: hypothyroidism
AXR: megacolon
Barium enema: megacolon, diverticular disease, colorectal cancer
Sigmoidoscopy: diverticular disease, colorectal cancer, inflammatory bowel disease
Colonoscopy: diverticular disease, colorectal cancer, inflammatory bowel disease
Anal manometry: Hirschsprung’s disease
MRI of L-S spine: intraspinal problems such as tethered cord, tumors, sacral agenesis
References:
Evaluation of Constipation. American Family Physician Volume 65, Number 11, June 1,
2002.
Evaluation and Treatment of Constipation in Infants and Children. American Family
Physician Number 73, February 1, 2006.
Dr. Chan Pang Fai
11) Diarrhoea
 Disorders of the upper GIT tends to produce diarrhea stools that are copious,
watery or fatty, pale yellow or green
 Colonic disorder tends to produce stools that are small, of variable consistency,
brown and may contain blood or mucus
 Acute gastroenteritis should be regarded as a diagnosis or exclusion
 No investigations are necessary for acute self-limiting diarrhoea
Acute
Dietary indiscretions (e.g. binge eating)
Food allergies in children: milk, soya bean, wheat, eggs
Infective gastroenteritis/enteritis: gastroenteritis=vomiting + diarrhea,
enteritis=diarrhea only, incubation period within 3-5 days, typical food: milk, water,
chicken, viral (rotavirus, norovirus, adenovirus), bacterial (Salmonella sp.,
Campylobacter jejuni, Shegella sp., enteropathic E. coli, enterohaemorrhagic strains
of E.coli (e.g. O157, O111:H8)
Traveller’s diarrhea: acute gastroenteritis can persist into a chronic phase, need to
consider cholera, typhoid, paratyphoid, malaria and amoebiasis
Microbial food poisoning: incubation period within 24 hrs, S. aureus within 2-4 hrs,
typical food: chicken, meat, seafood, rice, custards and cream (S. aureus), toxins from
Staphylococcus aureus, Salmonella sp., Clostridium perfringens, Vibrio
parahaemolyticus, Aeromonas hydrophilia, Bacillus cereus
Non-microbial food poisoning: mushrooms, toadstools, immature or sprouting
potatoes, fish, mussels, grain esp rye, fava beans
Drugs: alcohol, laxatives, metformin, acarbose, colchicines, H2-blockers, statins,
actifed, aldactone, allopurinol, antibiotics, vitamin C, statins, beta-blockers, benadryl,
betaloc, bisolvon, ACEIs, NSAIDs and COX-II, folic acid, indapamide, thyroxine,
theophylline, fosamax, lamisil, levodopa, lopid, methyldopa, minipress, PPIs,
persantin, phenytoin, glitazones, transamin, warfarin
Traveller’s diarrhea: acute gastroenteritis can persist into a chronic phase, bacteria
(enterotoxigenic E. coli, other E.coli types, Campylobacter Salmonella (typhoid and
non-typhoid), Shigella, Aeromonas, Vibroid (Cholera and non-cholera),
enterotoxigenic S. aureus, Yersinia enterocolitica, S. entertica), Parasites (Giardia
lambia, Entamoeba histolytica, Cyclospora cayetanensis, Cryptosporidium parvum),
Viruses (rotavirus, noroviruses, hepatitis A, hepatitis E)
Dr. Chan Pang Fai
Intussuception and malrotation
Pelvic appendicitis/pelvic abscess
Urinary tract infection: in children
Diabetes mellitus: in children
Other infections especially in children: pneumonia, septicaemia, otitis media<5 years
Fecal impaction with spurious diarrhea
Ischaemic colitis
Chronic
Diet
Food allergies in children: milk, soya bean, wheat, eggs
Lactose intolerance (lactase deficiency)
Drugs: antibiotics, laxatives, osmotic agents such as lactose and sorbitol in chewing
gum, alcohol, thyroxine, vitamin C
Diverticular disorder
Chronic infections: more likely due to protozoal infection (amoebiasis, giardiasis,
Cryptosporodium), Yersinia, HIV infection
Inflammatory bowel disease: ulcerative colitis, Crohn’s disease, pseudomembranous
colitis
Carcinoma of bowel
Hyperthyroidism
Diabetes mellitus
Addison’s disease
Carcinoid tumours
Short bowel syndrome
Zollinger-Ellison syndrome
Amyloidosis
Coeliac disease
Whipple’s disease
Radiation therapy
Post-GIT surgery
Gay bowel
Investigations
Stool for cultures: indicated if acute diarrhea lasts longer than 7 days or chronic
diarrhea, need special requests for Campylobacter sp., C. difficile and toxin, Yersinia
Dr. Chan Pang Fai
sp., Cryptosporidium sp., Aeromonas sp.
Stools for parasites and red and white cells (warm specimen for amebiasis)
Haemagglutination tests for ameobiasis
C. difficile tissue culture assay
CBP: inflammatory bowel disease, colorectal cancer
ESR: inflammatory bowel disease, colorectal cancer
Iron profile: if anaemia
LFT: inflammatory bowel disease
RFT: electrolyte disturbance in severe diarrhoea
Calcium and magnesium: hypocalcaemia and hypomagnesium in severe diarrhoea
TFT: hyperthyroidism
HIV tests
Antibody tests: IgA antiendomysial, IgA transglutaminase for celiac disease
Malabsorption study
AXR is of limited value
Small bowel enema
Barium enema especially double contrast: diverticular disorder, inflammatory bowel
disease, colorectal cancer
Endoscopy: diverticular disorder, inflammatory bowel disease, colorectal cancer
References:
Traveller’s diarrhea. American Family Physician Volume 71, Number 11, June 1, 2005.
Dr. Chan Pang Fai
12) Dizziness and Vertigo

 Dizzy means unsteadiness or lightheadedness without movement or motion or
spatial disorientation.
 Vertigo is “a sudden sense of movement” and should describe a hallucination of
rotation of self or the surroundings in a horizontal or vertical direction.
 The term “dizziness” is generally used collectively to describe all types of
equilibrium disorders.
 93% of primary care patients with vertigo have BPPV, acute vestibular neuronitis,
or Meniere’s disease.
 Laboratory tests such as electrolytes, glucose, blood counts, and thyroid
function tests identify the etiology of vertigo in fewer than 1% of patients with
dizziness. They may be appropriate when patients with vertigo exhibit signs or
symptoms that suggest the presence of other causative conditions.
 Physicians should consider neuroimaging studies in patients with vertigo who
have neurologic signs and symptoms, risk factors for cerebrovascular disease, or
progressive unilateral hearing loss.
Dizziness
Pseudovertigo: giddiness (giddiness is a typical psychoneurotic symptom) or
lightheadedness, fainting or syncopal episodes, disequilibrium (disequilibrium is
usually of neurogenic origin)
Anxiety and panic attacks: hyperventilation
Postural hypotension
Simple faint: vasovagal
Post-head injury
Cervical dysfunction/spondylosis: generation of abnormal impulses from
proprioception in the upper cervical spine, or by osteophytes compressing the
vertebral arteries in the vertebral canal
Cardiovascular: arrhythmias, myocardial infarction, aortic stenosis
Ear wax: ostosclerosis
Drugs: alcohol, illicit drugs and other drugs, aspirin and salicylates, antibiotics
(streptomycin, gentamicin, kanamycin, tetracyclines), antiepileptics (phenytoin),
antidpressants, antihypertensives, antihistamines, quinine-quinidine,
tranquillisers (phenothiazines, phenobarbitone, benzodiazepines, diuretics,
glyceryl trinitrate
Dr. Chan Pang Fai
Anaemia
Hypertension
Eye: especially disorders causing diplopia
Depression
Diabetes: hypoglycaemia, autonomic neuropathy
Thyroid disorders: hyperthyroidism and hypothyroidism
Menopausal symptoms
Dizzy turns: in girls in late teens due to blood pressure fluctuations
Addison’s disease
Autonomic neuropathy
Subclavian steal
Shy-Dragar syndrome
Brain tumours
Vertigo
Vertigo
Peripheral disorders
Labyrinth:
Motion sickness
Labyrinthitis: viral (e.g. influenza, mumps, measles) or suppurative
Meniere’s syndrome
Benign paroxysmal positional vertigo (BPPV)
Drugs
Trauma
Chronic suppurative otitis media (acute otitis media does not cause
vertigo)
Perilymphatic fistula
th
8 nerve:
Vestibular neuronitis (acute vestibulopathy/vesticular failure = vestibular
neuronitis + labyrinthitis)
Acoustic neuroma/vestibular schwannoma
Drugs: phenytoin causing cerebellar dysfunction
Cervical vertigo
Herpes zoster oticus (Ramsay Hunt syndrome)
Otosclerosis
Central disorders
Brain stem
Dr. Chan Pang Fai
Vertebrobasilar insufficiency
Infarction: lateral medullary syndrome due to posterior inferior cerebellar
artery thrombosis
Cerebellum
Degeneration
Tumours
Migraine: vertiginous migraine
Multiple sclerosis
Neurosyphilis
Focal epilepsy: complex partial seizures
CNS infection: meningitis, meningoencephalitis, cerebral abscess
Primary and secondary malignancy in elderly
Psychosomatic vertigo
Investigations
CBP: anaemia
FBG: diabetes mellitus
ECG: arrhythmias
Holter: arrhythmias
Pure tone audiometry (PTA): sensorineural deafness in Meniere’s syndrome, acoustic
neuroma
Brain-stem evoked audiometry
Caloric test: vestibular dysfunction
Rotational tests: vestibular dysfunction
Visual evoked potentials: Multiple sclerosis
Electrocochleography: characteristic changes in electrocochleography
Electro-oculography (electronystagmography)
Radiology: CXR (? Bronchial carcinoma), x-ray C-spine, CT brain (superior to detect
any petrous bone abnormality or cerebellar haemorrhage, and as a follow up tool for
trauma induced vertigo), MRI brain (MRI is superior to CT for the diagnosis of vertigo
because of its superior ability to visualize the posterior fossa)
EEG: epilepsy
Dr. Chan Pang Fai
Diagnosing Vertigo
Algorithm for an initial approach for diagnosing the cause of vertigo. (MRI = magnetic
resonance imaging.)
References:
Vertigo. Australian Family Physician Volume 37, Number 5, May 2008.
Initial Evaluation of Vertigo. American Family Physician Volume 73, Number 2,
January 15, 2006.
Dr. Chan Pang Fai
13) Dysmenorrhoea
 Primary dysmenorrhoea usually commences within 1-2 years after the
menarche and become more severe with time up to about 20 years. If affects
about 50% of menstruating women and up to 95% of adolescents.
Primary (functional) dysmenorrhoea
Secondary dysmenorrhoea
Intrauterine
Adenomyosis
Menorrhagia-passing clots
Endometrial carcinoma
Fibroids
IUCD
Miscarriage
Haematometra from congenital anomalies
Cervical stenosis
Intrauterine polyp
Extrauterine
Endometriosis
Pelvic inflammatory disease (PID)
Ovarian carcinoma
Adhesions
Ectopic pregnancy
Retained tampon
Nongynaecological
Psychosomatic disorders
Depression
Chronic constipation
Inflammatory bowel disease/diverticulitis
Musculoskeletal: referred pain
Renal calculi/urinary tract infection
Dr. Chan Pang Fai
Investigations
Cervical swab: high vaginal swab for culture and gonorrhea, endocervical swab for
Chlamydia if suspected PID
CBP: associated menorrhagia, PID
TFT: associated menorrhagia
CA-125: increased in endometriosis and ovarian cancer
MSU for culture: to exclude urinary tract pathology
USG/transvaginal USG
Laparoscopy
Hysteroscopy or hysterosalpingography
CT abdomen and pelvis: to exclude pelvic mass
References
Dysmenorrhoea. Australian Family Physician Volume 35, Number 11, November 2006.
Dysmenorrhoea. American Family Physician Volume71, Number 2, January 15, 2005.
Dr. Chan Pang Fai
14) Dyspepsia (Indigestion)

 Dyspepsia embraces the following: nausea, heartburn/regurgitation, upper
abdominal discomfort, lower chest discomfort, acidity, epigastric fullness or
unease, abdominal distension.
 Consider heartburn as ischaemic heart disease until proved otherwise.
 All patients with dysphagia must be investigated to rule out malignancy.
 Investigations tend to be unrewarding in most instances of dyspepsia and could
be postponed if the history is suggestive of a functional cause and the
symptoms are not severe.
 An organic cause is found in only about 40% of patients with dyspepsia.
 Age is important in determining the extent of investigations, which are more
relevant in those over 40 years.
 It is important to consider carcinoma of the stomach in the elderly.
 Dyspepsia is an uncommon problem in children but can be caused by drugs,
oesophageal disorders and gastro-oesophageal reflux in particular. Reflux can be
considered to be physiological or pathological.
Gastrointestinal disorders
Gastro-oestrophageal reflux including hiatus hernia
Functional (non-ulcer) dyspepsia
Oesophageal motility disorders (dysmotility)
Peptic ulcer
Upper GIT malignancies: oesophagus, stomach, pancreas
Hepatobiliary disease: hepatitis, biliary dyskinesia, cholelithiasis
Pancreatitis
Upper GIT inflammation: gastritis, duodenitis, Crohn’s disease
Post-vagotomy
Non-gastrointestinal disorders
Myocardial ischaemia
Drug reaction: alcohol, acarbose, anticholinergics, aspirin, bisphosphonates (e.g.
Fosamax), calcium-channel blockers, corticosteroids, COX-II, digitalis, iron,
lipid-lowering agents, metformin, narcotics, nicotine, orlistat (Xenical), NSAIDs, slow
Dr. Chan Pang Fai
K, theophylline, TCAs, tetracycline
Herbs: garlic, ginkgo, saw palmetto, feverfew, chaste tree berry , white willow
Alcohol effect
Food intolerance: carbohydrate malabsorption
Intestinal parasites: giardia species, strongyloides species
Summarization
Anxiety/stress
Depression
Pregnancy
Diabetes
Thyroid disorders
Hyperparathyroidism: hypercalcaemia
Hyperkalaemia
Connective tissue disease
Mesenteric ischaemia
Zollinger-Ellison syndrome
Kidney failure
Rome II diagnostic criteria for functional dyspepsia

Patients meets the following criteria for at least 12 weeks (which need not be
consecutive) within the preceding 12 months:
 Persistent or recurrent symptoms (pain or discomfort centered in the
upper abdomen)
 No evidence of organic disease (including on upper endoscopy) that is likely
to explain the symptoms
 No evidence that dyspepsia is relieved exclusively by defecation or
associated with the onset of a change in stool frequency or stool form (i.e.,
not irritable bowel syndrome)
Investigations
LFT: hepatitis
Hepatitis serology: hepatitis
OGD: indicated for the alarm symptoms: abnormal symptoms of reflux/dyspepsia,
change of symptoms, dysphagia, unexplained weight loss, GI bleed, pain radiating to
back, pain waking at night, family history of gastrointestinal carcinoma, abnormal
signs on examination
Barium meal: OGD is superior to barium meal
Dr. Chan Pang Fai
H. pyloric tests: see abdominal pain
24hrs pH and manometry: GERD
USG abdomen: biliary diseases, hepatitis
CT abdomen: pancreatitis
Evaluation and management of non-ulcer dyspepsia.
References
Upper Abdominal Pain. Australian Family Physician Volume 37, Number 8, November
20086.
Evaluation and Management of Nonulcer Dyspepsia. American Family Physician
Volume 70, Number 1, July 1, 2004.
Dr. Chan Pang Fai
15) Dysuria
 Dysuria or difficult and/or painful micturition, which is characterized mainly by
urethral and suprapubic discomfort, indicates mucosal inflammation of the
lower genitourinary tract, (i.e. the urethra, bladder or prostate).
 Inflammation usually results in the frequent passage of small amounts of urine
and a sense of urgency.
 Infection is the most common cause of dysuria and presents as cystitis,
prostatitis, pyelonephritis, or urethritis.
 Urethritis usually causes pain at the onset of micturition.
 Suprapubic discomfort is a feature of cystitis.
 Vaginitis is an important cause and must be considered. Vaginitis is the most
common cause of dysuria in the adolescent age group and is a relatively
common cause of dysuria in family practice, estimated around 15%.
 If vaginitis is suspected, a pelvic examination should be carried out to inspect
the genitalia and obtain swabs.
 Acute bacterial cystitis accounts for about 40% of causes of dysuria.
 Dysuria and discomfort is a common feature of postmenopausal syndrome, due
to atrophic urethritis.
 Unexplained dysuria could be a pointer to Chlamydia urethritis.
 Urinary infection and other disorder can be quite asymptomatic.
 Urinalysis may not be needed in healthier patients who have uncomplicated
medical histories and symptoms. In most patients, however, urinalysis can help
to determine the presence of infection and confirm a suspected diagnosis.
 Urine cultures and both urethral and vaginal smears and cultures can help to
identify sites of the infection and causative agents.
 Although radiography and other forms of imaging are rarely needed, these
studies may identify abnormalities in the upper urinary tract when symptoms
are more complex.
UTI especially cystitis
Urethritis
Urethral syndrome (female): symptoms consistent with a lower UTI but without the
presence of significant bacteria and conventional pathogens
Vaginitis
Neoplasia: bladder, prostate, urethra
Dr. Chan Pang Fai
Severe infections: gonorrhea, NSU, genital herpes, Schistosoma haematobium
Spondyloarthropathies: Reiter’s syndrome, Behcet’s syndrome
Calculi
Menopause syndrome
Prostatitis
Cervicitis
Epididymo-orchitis
Foreign bodies in LUT
Acidic urine
Interstitial cystitis
Urethral carbuncle/diverticuli
Vaginal prolapsed
Endometriosis
Obstruction: BPH, urethral stricture, phimosis, meatal stenosis
Drugs: ticarcillin, penicillin G, cyclophosphamide
Food: saw palmetto, pumpkin seeds
Poor perineal hygiene
Allergic reactions
Chemical irritants: deodorant sanitary pads, contraception foams, vaginal lubricants,
vaginal cosmetics, bubble baths, soaps
Psychogenic conditions: somatization disorder, depression, anxiety
Sexual abuse
Investigations
Urine multistix: used for screening, the specificity of the dipstick test makes it useful
for identifying haematuria, pyuria, or bacteriuria, pyuria detected on urinalysis is
associated not only with bacterial UTI, but also with T. vaginalis, C. trachomatis and
other infections.
MSU for microscopy and culture:
 Indications: pregnant women, patients with disorders that affect immune
status such as diabetes mellitus, all male patients with suspected UTI
 pyuria is diagnosed by the presence of three to five white blood cells per
high-power field
 sterile pyuria may be present in patients with prostatitis, nephrolithiasis,
urologic neoplasms, and fungal or mycobacterial infections
 cultures are not essential in selected young women when clear-cut signs
and symptoms of acute dysuria indicate a high probability of
Dr. Chan Pang Fai
uncomplicated cystitis, when symptoms are present
 a count of 103 CFU per ml is generally diagnostic of infection
 urine culture is helpful for determining antimicrobial susceptibility of
infecting bacteria
Urine for cytology: gold standard for bladder cancer screening, poor sensitivity but
excellent specificity
Urethral swab for sexually transmitted infections: trichomonas vaginalis, candidia,
neisseria gonorrhoea
HVS for cultures, gonorrhea
ECS for Chlamydia
PCR tests for N. gonorrhea and C. trachomatis
Radiology and other studies: imaging studies and other diagnostic tests are indicated
when the diagnosis is in doubt, when patients are severely ill or
immunocompromised and do not respond to antibiotic therapy, and when
complications are suspected
Cystoscopy: detection of bladder or urethral pathology, confirmation of diagnosis of
interstitial cystitis
Evaluation of Acute Dysuria*
Dr. Chan Pang Fai
*--Because UTI is the most common cause of dysuria in men and women, urinalysis may be useful at any
stage of the evaluation to confirm or rule out an infectious process
References
Evaluation of Dysuria in Adults. American Family Physician Volume 65, Number 8,
April 15, 2002.
Dr. Chan Pang Fai
16) Epistaxis
 A thorough examination of the nasopharynx, and a serological test (serum IgA
against the viral capsid antigen of the Epstein-Barr virus) should be offered to all
patients with a persistent enlargement of the upper cervical lymph nodes, nasal
symptoms especially blood-stained post-nasal drip, otological problems
(tinnitus, hearing impairment, middle ear effusion), headache or cranial nerve
dysfunction (5th or 6th nerve palsy).
Local causes
Idiopathic
Environmental factors: dry and cold air
Trauma including nose picking (epistaxis digitorum)
URTIs: common cold, influenza, sinusitis
Rhinitis
Medications: topical steroids
Foreign bodies
Intranasal polyps and benign tumours (papilloma, fibroma, osteoma, fibroangioma)
Irritants: smoking
Septal deviation
Nasopharyngeal carcinoma and paranasal tumours
Intracranial tumours
Vascular malformation/telangiectasia
Septal perforation
Systemic causes
Cardiovascular causes: arterosclerosis, hypertension
Systemic febrile infections, e.g. malaria
Drugs: anticoagulants, aspirin, NSAIDs
Liver disease: cirrhosis
Toxic agents
Blood disorders: leukaemia, thrombocytopenia, platelet dysfunction, haemophilia
Hereditary haemorrhagic telangiectasia
Dr. Chan Pang Fai
Investigations
CBP
Clotting profile
LFT: cirrhosis
EBV IgA-VCA titre: NPC, if positive, the EBV IgA-EA titre or serum EBV DNA
concentration (Sensitivity of an IgA-VCA titre of 1/10 for diagnosing NPC is 81%,
IgA-VCA results sensitivity in detecting NPC is only 70%, EBV DNA, which has a 95%
sensitivity for detecting NPC. The combination of IgA-VCA titre and EBV DNA
concentration has a sensitivity of 99% and a specificity of 96-98% for the detection of
NPC.)
CT: NPC and other tumours
References
Management of Epistaxis. American Family Physician Volume 71, Number 2, January
15, 2005.
Common Head and Neck Malignancies. The Hong Kong Practitioner Volume 26,
February 2004
Nasopharyngeal carcinoma Presenting Symptoms and Duration Before Diagnosis.
HKMJ Volume 3, Number 4, December 1997
Dr. Chan Pang Fai
17) Foot, ankle and heel pain

 Foot pain=podalgia
 Metatarsalgia=pain and tenderness over the plantar heads of the metatarsals
 Foot strain is probably the commonest cause of podalgia.
 Common causes include osteoarthritis, especially of the first
metatarsophalangeal joint, acute or chronic foot strain, plantar fasciitis, plantar
skin conditions such as warts, corns and calluses and various toenail problems
 Foot deformities such as flat feet (pes planus) are often painless
 Many foot and ankle problems are caused by unsuitable footwear and lack of
foot care.
 Osteoarthritis may occur in any of the joints of the foot but it commonly
involves the first MTPJ, leading to hallux rigidus. It can affect the subtalar joint,
but the ankle joint proper is usually not affected by osteoarthritis.
 If conservative treatment of plantar fasciitis fails to alleviate symptoms,
radiographs are advisable to check for other causes of heel pain such as stress
fractures, arthritis, or skeletal abnormalities. Heel spurs on X-rays are present in
asymptomatic persons, are nonspecific, and should not be construed as an
explanation for heel pain.
 Plain radiography is an important diagnostic tool in the initial evaluation of
patients with chronic foot pain.
General
Acute or chronic foot strain
Arthritis: OA, gout, RA, seronegative spondyloarthropathies (psoriasis, Reiter’s
syndrome, ankylosing spondylitis, and the inflammatory bowel disorders)
Diabetes: neuropathy [sensory (charcot), motor, autonomic, single nerve], sepsis,
vasculopathy
Peripheral neuritis: alcohol, vitamin B12 deficiency
Vascular: arteriosclerosis (claudication, gangrene), hemiplegia, Raynaud’s, regional
pain syndrome (Sudeck’s), chilblains
Infections: celullitis, septic arthritis, TB, actinomyces, osteomyelitis
Neoplasia: Paget’s disease of bone, osteoid osteoma, osteosarcoma, synovial
sarcoma, Ewing’s sarcoma, metastatic tumours
Other: hypermobility syndrome (including Marfan), erythema nodosum, painful
accessory bones (accessory tarsal navicular bones, os trigonum)
Dr. Chan Pang Fai
Ankle and hindfoot

Tendoachilles (bursitis, tendonitis, tear)
Posterior tibial tendonitis, rupture or subluxation
Flexor hallucis longus and flexor digitorum longus tendonitis
Plantar fasciitis
Sprain
Bruised heel (Policeman’s heel): fat pad contusion
Phlebitis
Cellulitis
Osteochondritis of calcaneum/calcaneal apophysitis (Sever’s)
Osteochondritis dissecans of talus (in adolescents)
Pitted keratolysis and juvenile plantar dermatosis (adolescents)
Midtarsal
Acute or chronic foot strain
Synovitis of subtaloid
Tarsal coalition
Hypermobility of transverse tarsal joints
Osteochondritis of navicular (Kohler’s)
Dorsal exostosis
Peroneus longus and brevis tendonitis
Flexor hallucis longus tendonitis
Forefoot (metatarsalgia)
Normal feet after prolonged standing
Bunion
Bunionette (Tailor’s bunion): A bunionette is a painful prominence on the lateral
aspect of the fifth metatarsal head
Intermetatarsal bursitis
Traumatic synovitis of MTPJ
MTPJ arthritis
Sesamoiditis
March fracture
Freiberg’s disorder: Freiberg's infraction is an uncommon disorder of the forefoot
seen predominantly in active adolescent girls. It is an articular osteochondrosis that
occurs most commonly in the second metatarsal head, with the third metatarsal
Dr. Chan Pang Fai
head the next most frequent location.
Toes
Hallux valgus
Hallux rigidus
Varus little toe
Hammer toe: a deformity of the middle joint of the second, third, or fourth toe
causing it to be permanently bent, resembling a hammer.
Mallet toe: The toe bends down at the joint closest to the tip of the toe.
Clawed toe: extended MTPJ, flexion of PIP and DIP, often follows polio
Tendonitis of flexor halluxis longus
Corn
Wet corn
Ingrown toenail
Onychogryphosis
Subungual exostosis
Deep peroneal nerve entrapment
Digital nerve entrapment (Morton’s neuralgia): fibrous enlargement of an
interdigital nerve
Glomus tumour (benign harmatoma)
Sole/Heel
Plantar fasciitis
Callus
Plantar wart
Achilles tendonitis/peritendonitis/bursitis
Haglund’s disease: a bony spur on the superior aspect of the posterior calcaneus
Epidermoid cyst
Foreign body
Tender heel pad: atrophy, inflammation
Peroneal tendon tendonitis/dislocation
Rupture plantar fascia
Nerve entrapment: Tarsal tunnel syndrome, medial calcaneal nerve, nerve to
abductor digiti minimi
Calcaneal apophysitis (Sever’s)
Duputren’s (Ledderhose’s) contracture
Dr. Chan Pang Fai
Investigations
For systemic disease
FBG
RA tests
ESR/CRP
HLA-B27
Serum uric acid: gout
RFT: gout
Radiology:
X-ray ± stress and weight-bearing views: arthritis, avascular necrosis, Morton’s
neuroma, plantar fasciitis (to rule out other conditions), reflex sympathetic
dystrophy, neuropathic arthropathy
Radionuclide scans: avascular necrosis in bones, stress fractures, osteoid
osteomas, inflammatory osteoarthritis and similar lesions, metastatic tumours,
osteomyelitis
CT: stress fractures, tarsal coalition
MRI: stress fracture, abnormal soft tissue structures including tendinopathy,
osteomyelitis, Morton’s neuroma, painful accessory bones, tarsal tunnel
syndrome, plantar fasciitis
USG: tendon problems, neruoma, high resolution USG is used to diagnose
disorders of the Achilles tendon and to locate foreign bodies
Nerve conduction studies and electromyography: neuropathy, nerve entrapment
Ottawa rules for ankle and foot x-ray

 These rules are a quick and reliable method of selecting which patients with
ankle and foot injuries need X-rays to exclude a fracture.
Ankle injury
An X-ray of the ankle is necessary when the patient has pain over the medial or
lateral malleolar zone and any of the following findings:
 There is bone tenderness on palpation of the distal 6cm of the fibula (posterior
tip of lateral malleolus)
 There is bone tenderness on palpation of the distal 6cm of the tibia (posterior
tip of medial malleolus)
 There was an inability to bear weight (walk four steps) both immediately after
injury and during the clinical examination
Dr. Chan Pang Fai
Foot injury
Refer for a foot X-ray (suspected mid-foot fracture) if there is pain in the mid-foot and
any one of:
 Bone tenderness at fifth metatarsal bone
 Bone tenderness at the navicular bone
 Inability to weight bear immediately after injury and when seen
References
Diagnosing Heel Pain in Adults. American Family Physician Volume 70, Number 2, July
15, 2004.
Radiologic Evaluation of Chronic Foot Pain. American Family Physician Volume 76,
Number 7, October 1, 2007.
Dr. Chan Pang Fai
18) Galactorrhoea
 Galactorrhoea, or inappropriate lactation, occurs in approximately 20 to 25% of
women.
 Although galactorrhoea is not associated with breast cancer, it can be caused by
neoplastic processes in the brain and pituitary gland.
 Approximately 20% of women with galactorrhoea have radiologically evident
pituitary tumours, and the prevalence increases to 34% in women who also
have amenorrhoea.
Physiologic conditions (14%)
Pregnancy and postpartum state
Breast stimulation
Fluctuating hormone levels during puberty or menopause
“Witch’s milk” in neonates: precipitous drop in maternal oestrogen and
progesterone levels after delivery
Medications and herbs (20%)
Antidepressants and anxiolytics: alprazolam, buspirone, MAOI, SSRIs, TCAs
Antihypertensives: atenolol, methyldopa, reserpine, verapamil
Antipsychotics
H2-blockers
Hormones: conjugated estrogen and medroxyprogesterone, Depo-Provera, OCPs
Phenothiazines: chlorpromazine, prochlorperazine
Other drugs: amphetamines, anesthetics, arginine, cannabis, cisapride,
cyclobenzaprine, danazol, dihydroergotamine, domperidone, isoniazid,
metoclopramide, octreotide, opiates, rimantadine, sumatriptan, valproic acid
Herbs: anise, blessed thistle, fennel, fenugreek seed, marshmallow, nettle, red
clover, red raspberry
Neoplastic processes (18%)
Pituitary adenoma (prolactinoma)
Bronchogenic carcinoma
Renal adenocarcinoma
Lymphoma
Craniopharyngioma
Hydatidiform mole
Hypernephroma
Dr. Chan Pang Fai
Mixed growth hormone-secreting and prolactin-secreting tumours
Null-cell adenoma
Hypothalamic-pituitary disorders (<10%)
Craniopharyngioma and other tumours
Infiltrative conditions: sarcoidosis, tuberculosis, schistosomiasis
Pituitary-stalk resection
Multiple sclerosis
Empty-sella syndrome
Systemic diseases (<10%)
Hypothyroidism
Chronic renal failure
Cushing’s disease
Acromegaly
Chest wall irritation (<10%)
Irritating clothes or ill-fitting brassieres
Herpes zoster
Atopic dermatitis
Burns
Breast surgery
Spinal cord injury or surgery
Spinal cord tumour
Esophagitis
Oesophageal reflux
Idiopathic (35%)
Hyperprolactinaemia
Euprolactinaemia
Investigations
Nipple discharge for microscopy: fat globules in milk
Nipple discharge for cytology
Pregnancy test
Prolactin level: a level greater than 200µg/L is almost always associated with a
prolactinoma or other prolactin-secreting tumour
RFT: chronic renal failure
TSH: hypothyroidism
Serum cortisol, growth hormone and insulin-like growth factor levels: cushingnoid
features or acromegalic features
Dr. Chan Pang Fai
MRI brain: symptoms suggestive of an intracranial mass, galactorrhoea with
amenorrhoea, or an elevated prolactin level; if a patient has galactorrhoea associated
with amenorrhoea or oligomenorrhea, even with a normal prolactin level, the risk of
a pituitary adenoma is still significant, and an imaging study of the gland is warranted
Mammography: not necessary unless other findings on the physical examination are
suggestive of breast pathology
Evaluation of Galactorrhea
References
Evaluation and Treatment of Galactorrhoea. American Family Physician Volume 63,
Number 9, May 1, 2001.
Dr. Chan Pang Fai
19) Gynaecomastia
 Gynaecomastia is the benign proliferation of glandular tissue of the male breast.
 If present in adult men, look for evidence of hypogonadal states such as
Klinefelter’s syndrome and secondary testicular failure.
Physiological
Infancy: 60-90% of infants have transient gynaecomastia due to oestrogenic
stimulation from the mother and placenta
Puberty: 30-60% of boys develop transient gynaecomastia (usually develops
after the age of 10 years and resolves by age 17 years
Aging: gynaecomastia is seen in an increasing number of normal adult men with
increasing age (65% age 80 years)
Drugs: oestrogen and oestrogen agonists, androgens, anabolic steroids, digoxin,
calcium antagonists, cyproterone, spironolactone, amiodarone, tricyclic
antidepressants, cimetidine
Drugs of abuse: alcohol, amphetamines, heroin, marijuana
Klinefelter’s syndrome: primary hypogonadism
Secondary testicular failure/hypogonadism (e.g. orchitis, orchidectomy, traumatic
atrophy)
Liver failure
Renal disease
Hyperthyroidism
Testicular feminization syndrome
Testicular tumour
Oestrogen-secreting tumours: adrenal carcinoma, Leydig cell tumour
Idiopathic: 25%
Investigations
hCG: The β subunit of human chorionic gonadotropin is secreted also by some

cancers including choriocarcinoma, germ cell tumors, hyatidiform mole formation,
teratoma with elements of choriocarcinoma (this is rare), and islet cell tumor. For
this reason a positive result in males can be a test for cancer, The normal range for
men is between 0-5 IU/ml, although cancer should not automatically be suspected if
the level is <30.
Dr. Chan Pang Fai
Oestradiol: Males with sex chromosome genetic conditions such as Klinefelters
Syndrome will have a higher level of estradiol.
Testosterone: low in hypogonadism
LH and FSH: LH and FSH high in testicular failure
LFT
RFT
TFT
Testicular USG
CT abdomen
References
Management of Benign Breast Conditions. Australian Family Physician Volume 34,
Number 5, October 2005.
Dr. Chan Pang Fai
20) Haematuria
 Macroscopic haematuria is always abnormal except in menstruating women.
 Small amount of blood (1mL/1000ml urine) can produce macroscopic
haematuria.
 Microscopic haematuria includes the presence of red blood cells (RBC) > 8000
per mL of urine (phase contrast microscopy) or >2000 per mL of urine (light
microscopy) representing the occasional RBC on microscopic examination.
Microscopic haematuria is clinically significant when three to five red blood cells
per high-power field are visible.
 The prevalence of asymptomatic microscopic haematuria in adults ranges from
0.19 to 21%.
 The prevalence of asymptomatic haematuria is approximately 0.5 to 2% in
children.
 Urine dipstick evaluation may be misleading because it lacks the ability to
distinguish red blood cells from myoglobin or haemoblobin. A positive finding
on urine dipstick testing should be evaluated further by microscopic analysis to
confirm the finding of RBCs.
 Joggers and athletes engaged in very vigorous exercise can develop transient
microscopic haematuria.
 Microscopic (asymptomatic haematuria) can be classified as either: glomerular
(from kidney parenchyma) or non-glomerular (urinary tract).
 Microscopic haematuria is often an incidental finding but may be associated
with urologic malignancy in up to 10% of adults.
 Common sources of macroscopic haematuria are the bladder, urethra, prostate
and kidney.
 Macroscopic haematuria occurs in 70% of people with bladder cancer and 40%
with kidney cancer.
 It is important to exclude kidney damage, so patients should have blood
pressure, urinary protein, and plasma creatinine levels measured as a baseline.
 All patients presenting with macroscopic haematuria or recurrent microscopic
haematuria require judicious investigation, which may involve both radiological
investigation of the upper urinary system and visualization of the lower urinary
system to detect or exclude pathology. But for children with asymptomatic
microscopic haematuria, diagnostic evaluations may not be needed. Follow-up is
necessary because, in rare cases, microscopic haematuria is the first sign of
occult renal disease.
Dr. Chan Pang Fai
 The AUA recommends that patients with microscopic haematuria have
radiographic assessment of the upper urinary tract followed by urine cytology
studies.
 The AUA recommends that all patients older than 40 years and those who are
younger but have risk factors for bladder cancer obtain cystoscopy to complete
the evaluation of microscopic haematuria.
 The key radiological investigation is the intravenous urogram (pyelogram),
unless there is a history of iodine allergy, severe asthma or other
contraindications, when ultrasound is the next choice.
Infection:
Cystitis/urethrotrigonitis (female)
Urethritis (male)
prostatitis
Calculi: kidney, ureteric, bladder
Cardiovascular: kidney infarction, kidney vein thrombosis, prostatic varices
Neoplasia: kidney tumour, urothelial (bladder, kidney pelvis, ureter), carcinoma
prostate
Severe infections: infective endocarditis, kidney tuberculosis, acute
glomerulonephritis, Blackwater fever
IgA nephropathy
Kidney papillary necrosis
Urethral prolapsed/carbuncle
Pseudohaematuria (e.g.. beetroot, red lollies or berries in diet; porphyria, red
coloured confectionery, free haemoglobin in haemoglobinuria, myoglobin, drugs (e.g.
pyridium, phenolphthalein)
Benign prostatic hyperplasia
Trauma: blunt or penetrating
Foreign bodies
Bleeding disorders
Exercise
Radiation cystitis
Menstrual contamination
Hydronephrosis
Henoch-Scholein purpura
Bilharzia (Schistosomiasis)
Dr. Chan Pang Fai
Polycystic kidneys
Kidney cysts
Endometriosis (bladder)
Systemic vasculitides
Drugs: cytotoxics, anticoagulants, aminoglycosides, amitriptyline, analgesics,
anticonvulsants, aspirin, busulfan, chlorpromazine, cyclophosphamide, diuretics, oral
contraceptives, penicillins, quinine, rifampin, vincristine
Munchausen’s syndrome (artefactual haematuria)
Recognized Causes of Microscopic Hematuria
Glomerular causes Nonglomerular causes
Alport's syndrome Vascular disease
Fabry's disease Arteriovenous malformation
Goodpasture's syndrome Malignant hypertension

Hemolytic uremia
Renal artery
Henoch-Schönlein purpura
embolism/thrombosis
Immunoglobulin A nephropathy
Renal venous thrombosis
Lupus nephritis
Sickle cell disease
Membranoproliferative glomerulonephritis
Extrarenal
Mesangial proliferative glomerulonephritis
Benign prostatic hypertrophy
Nail-patella syndrome
Calculi
Other postinfectious glomerulonephritis: endocarditis, viral
Poststreptococcal glomerulonephritis Coagulopathy related
Thin basement membrane nephropathy (benign familial hematuria) Drug induced (warfarin)
Wegener's granulomatosis Secondary to systemic disease
Nonglomerular causes Congenital abnormalities

Renal (tubulointerstitial)
Endometriosis
Acute tubular necrosis
Factitious
Familial
Foreign bodies
Hereditary nephritis
Infection: prostate, epididymis,
Medullary cystic disease
urethra, bladder
Multicystic kidney disease
Inflammation: drug or radiation
Polycystic kidney disease induced
Infection: pyelonephritis, tuberculosis (e.g., travel to Indian subcontinent), Perineal irritation
schistosomiasis (e.g., travel to Africa) Posterior ureteral valves
Interstitial nephritis Strictures
Drug induced: penicillins, cephalosporins, diuretics, nonsteroidal Transitional cell carcinoma of
Dr. Chan Pang Fai
anti-inflammatory drugs, cyclophosphamide (Cytoxan), chlorpromazine ureter, bladder
(Thorazine), anticonvulsants Trauma: catheterization, blunt
Infection: syphilis, toxoplasmosis, cytomegalovirus, Epstein-Barr virus trauma
Systemic disease: sarcoidosis, lymphoma, Sjögren's syndrome Tumor
Loin pain-hematuria syndrome Other causes
Metabolic: Hypercalciuria, Hyperuricosuria Exercise hematuria
Renal cell carcinoma Menstrual contamination
Solitary renal cyst Sexual intercourse
Investigations
Urinalysis by dipstick
Urine microscopy: formed RBC in true haematuria, red cell casts or dysmorphic red
cells indicate glomerular bleeding
Urine culture
Early morning urine for TB culture x 3
Urine cytology: useful to detect bladder and lower tract malignancies but is usually
negative with carcinoma of kidney
CBP: thrombocytopenia, infection, anaemia
Clotting profile: bleeding tendency
ESR: infection
RFT: kidney damage, glomeurlonephritis or other kidney diseases
Antistreptolysin O titres: glomerulonephritis
Radiological techniques:
IVU: key investigation but limited sensitivity for detecting small renal
masses<3cm, superior to CT in detecting transitional cell carcinoma of kidney or
ureter but has limited application in the evaluation of the bladder and urethra
CT urography: equal or superior sensitivity in IVU for causes of haematuria
USG: more sensitive than IVU in detecting renal cell carcinoma, less sensitive
than at detecting LUT abnormalities
CT abdomen and pelvis: more accurate for evaluating patients with renal colic,
for identifying small renal parenchymal masses, aneurysms in vessels run along
the ureter, renal and perirenal abscesses
Kidney angiography
Retrograde pyelography
Cystoscopy and ureteroscopy: cystoscopy is advisable in all patients regardless of the
IVU findings
Dr. Chan Pang Fai
Kidney biopsy: glomerular disease
Algorithmic approach to microscopic hematuria in adults. (CVA = costovertebral
angle; RBC = red blood cell.)
References
Assessment of Microscopic Hematuria in Adults. American Family Physician Volume
73, Number 10, May 15, 2006.
Is Diagnosing Asymptomatic Hematuria in Children Useful? American Family
Physician, February 15, 2006.
Radiologic Evaluation of Hematuria: Guidelines from the American College of
Radiology’s Appropriateness Criteria. American Family Physician Volume 78, Number
3, August 1, 2008.
Dr. Chan Pang Fai
21) Haemoptysis
 Haemoptysis must be distinguished from blood-stained saliva caused by
nasopharyngeal bleeding or sinusitis and from haematemesis.
 In 7 to 34% of patients with haemoptysis, no identifiable cause can be found
after careful evaluation.
URTI
Acute bronchitis
Chronic bronchitis
Bronchiectasis
Lobar pneumonia (rusty sputum)
Mycetoma
Tuberculosis
Neoplastic: bronchogenic carcinoma, metastatic carcinoma
Pulmonary infarction/embolism
Foreign body inhalation
Cardiac: left ventricular failure, mitral stenosis (elevated pulmonary venous pressure)
Anticoagulant therapy
Blood disorders
Idiopathic pulmonary haemosiderosis
Goodpasture’s syndrome
Wegener’s granulomatosis
Lupus pneumonitis
Osler-Weber-Rendu disease
Arteriovenous malformation
Trauma
Iatrogenic: endotracheal tubes
Pulmonary endometriosis
Idiopathic
Investigations
CXR: bronchitis, pneumonia, neoplasm, pulmonary infarction/embolism,
cardiomegaly
CBP: infection, bleeding disorders, anaemia
Clotting profile: bleeding disorders
Dr. Chan Pang Fai
ESR: infection, bronchial carcinoma, autoimmune disorders (Wegener’s syndrome,
SLE, sarcoid, Goodpasture’s syndrome)
Sputum for culture: chronic infection
Sputum for AFB x3 and TB culture: TB infection symptoms
Sputum for cytology: malignancy
Sputum for PCR tests for TB
Lung function tests: asthma, COPD, interstitial lung disorders
CT lung: bronchogenic carcinoma, bronchiectasis
Bronchoscopy: bronchial neoplasm, foreign body
ECG: pulmonary emobolism
Algorithm for diagnosing nonmassive hemoptysis. (CT = computed tomography.)
References:
Haemoptysis: Diagnosis and Management. American Family Physician Volume 72,
Number 7, October 1, 2005.
Dr. Chan Pang Fai
22) Haemospermia/Haematospermia
 The initial step is to determine that the blood is actually in the semen and not
arising from warts inside the urethral meatus or from the partner.
 It usually occurs as an isolated event but can be secondary to urethral warts or
prostatitis, or with prostatomegaly or prostatic tumour.
 In most patients with haemospermia, no further diagnostic workup is needed.
 In younger men (<40yr), haematospermia is uniformly benign. Even in older
men, it is rarely associated with malignancy.
 Haemospermia is usually associated with inflammatory conditions of the
seminal vesicles or prostate. The condition is often self-limited and resolves
within 1-2 months.
 If a micro-urine shows no accompanying haematuria, and prostatic specific
antigen and blood pressure are normal, reassurance and a 6-weekly review is
appropriate as spontaneously cessation of haematospermia is the rule.
 If haemospermia persists beyond 2 months, further workup is recommended to
determine the cause.
 In approximately half the cases, the etiology is declared idiopathic. However,
this may reflect an incomplete evaluation.
Conditions of the prostate
Prostate biopsy
Prostatitis
Prostate carcinoma
Prostate telangiectasia and varices
Prostatic calculi
Prostate cyst
Conditions of the urethra

Urethritis
Urethral cysts, polyps, condyloma, and strictures
Seminal vesicle lesions

Seminal vesicle cysts
Malignancies of seminal vesicles
Amyloidosis of the seminal vesicles
Dr. Chan Pang Fai
Infections
TB
HIV
CMV
Herpes simplex
Chlamydia trachomatis
Enterococcus faecalis, ureaplasma urealyticum
Hydatid disease
Trauma
Haemorrhoidal sclerosing injection
Urethral self-instrumentation
Testicular and perineal blunt trauma
Systemic disorders
Severe hypertension
Chronic liver disease
Amyloidosis
Lymphoma
Bleeding diatheses (von Willebrand disease)
Investigations
Urinalysis and urine culture: urogenital infection, rate of positive results is low
(6-29%)
Urine for TB culture
Urethral swab for culture: urethritis
Semen analysis and culture: the role of semen analysis and culture remains unclear.
While advocated by some authors, the significance of a positive culture remains
uncertain because this may simply represent urethral contamination
PSA: recommended in all men older than 50 years and men older than 40 years with
a family history of prostate cancer.
CBP and clotting: for persistent haematospermia (>2mos) as associated with
coagulopathies
TRUS: single most important tool for evaluating haematospermia
MRI: able to demonstrate haemorrhage within the seminal vesicles or prostate
Cystourethroscopy: may aid the clinician in pinpointing the source of the bleeding
Seminal vesicle endoscopy: seminal vesicle calculi
Dr. Chan Pang Fai
References
JD Schiff. Hematospermia. eMedicine. November 25, 2008.
Dr. Chan Pang Fai
23) Hair loss

 About 50-100 hairs are shed daily without a reduction in density.
 At least 25% of hair must be shed before a noticeable loss of density occurs.
 Hair loss counts consistently above 100 per day indicate excessive hair loss.
 Adrogenic alopecia is the most common cause of human hair loss, affecting 50%
of men by age of 40 and up to 50% of women by age 60.
 In telogen effluvium, the traumatic event has preceded the hair loss by about 2
months.
 Although severe stress could precipitate alopecia areata, day-to-day stressors
are not considered to be a trigger.
 Laboratory tests are of little value in women with adrogenetic alopecia who do
not have characteristics of hyperandrogenism.
Focal hair loss
Alopecia areata
Tinea capitis
Trichotillomania
Traction alopecia
Cicatricial alopecia
Syphilis
Diffuse hair loss

Androgenetic alopecia/male-pattern baldness
Telogen effluvium (stress precipitants: any severe stress, childbirth (common), high
fever, weight loss, trauma (surgical or accidental), OCPs, malnutrition, haemorrhage)
Postpartum telogen effluvium
Alopecia areata (diffuse type: alopecia totalis and alopecia universalis)
Drugs: cytotoxics, thallium, amphetamines, anticoagulants (heparin, warfarin),
antiepileptics (phenytoin, sodium valproate, carbamazepine), antigout agents
(allopurinol, colchicines), antihelminthic agents (albendazole, mebendazole),
anti-inflammatories (indomethacin, gold, penicillamine, salicylate), anti-parkinson
(levodopa, bromocriptine), antithyroid agents/thyroxine/iodine, cardiovascular
agents (amiodarone, statins, clofibrate, selected ACEIs, selected beta-blockers),
cimetidine, gentamicin, hormones (OCPs, androgens, danazol), interferon, lithium,
methysergide, vitamin A derivatives/retinoids (roaccutane)
Dr. Chan Pang Fai
Hypothyroidism and hyperthyroidism
Nutritional: iron deficiency, severe dieting, zinc deficiency, malnutrition
Post-febrile state
Anagen effluvium: cancer chemotherapy and radiotherapy to the scalp
Loose anagen (growing hair) syndrome in children (autosomal dominant)
Scarring alopecia
Trauma including burn
Tinea capitis
Lichen planopilaris: a variant of lichen planus
Discoid lupus erythematous
Folliculitis decalvans: a chronic folliculitis of the scalp, probably a response to
staphylococci
Pseudopelade: a slowly progressive, non-inflammatory scarring condition causing
patchy areas of hair loss without any obvious preceding skin disease
Investigations
Female androgenetic alopecia: prolactin, FSH, LH, 17-OH progesterone,
testosterone, Dehydroepiandrosterone (DHEAS) for hyperandrogenism
Telogen effluvium: TSH, other endocrine tests for metabolic disorder
Alopecia areata, telogen effluvium: ESR, ANA, RF for autoimmune disease
Alopecia areata: CBC for pernicious anaemia
Tinea capitis: fungal culture swab, KOH examination, fluorescence with Wood’s
lamp for fungal infection
Telogen effluvium: hair-pull test with microscopic evaluation (white bulb on shaft)
Tinea areata, environmental/external factor, systemic disease: hair-pull test with
microscopic evaluation (mid-shaft, fractured hairs)
Alopecia areata, alopecia totalis, alopecia universalis: hair-pull test with
microscopic evaluation (exclamation-point hairs)
Telogen effluvium: hair-pluck test (increased telogen:anagen ratio)
Unclear etiology, mixed signs/symptoms, failure to improve with treatment: scalp
biopsy
References
Common Hair Loss Disorders. American Family Physician Volume 68, Number 1, July 1,
2003.
Dr. Chan Pang Fai
24) Headache
 Migraine affects at least 10% of adult population. 5% of children suffer from
migraine by the age of 11 years.
 Many headaches previously considered to be tension are secondary to disorders
of the neck, eyes, teeth, temporomandibular joints or other structures.
 The commonest cause of headache presenting in general practice is respiratory
infection. The most common causes of chronic recurrent headache are so-called
transformed migraine, tension-type headache and combination headaches (mix
of components such as tension, depression, cervical dysfunction, vascular
headache, and drug dependence).
 A UK study placed headache from cervical spondylosis on almost equal terms
with migraine.
 Drug-induced headaches are common and must be considered in the history.
 In children the triad of symptoms – dizziness, headache and vomiting – indicates
medulloblastoma of the posterior fossa until proved otherwise.
 A typical triad of symptoms in an adult with a cerebral tumour (advanced) is
headache, vomiting and convulsions.
 A patient >55 years old presenting with unaccustomed headache has an organic
disorder such as TA, intracerebral tumour or subdural haematoma until proved
otherwise.
 The ESR is an excellent screening test to diagnose TA but occasionally can be
normal in the presence of active TA.
 CT scans and MRI have superseded other investigations in the diagnosis of
cerebral tumours and intracranial haemorrhage but should de ordered sparingly
and judiciously.
 A severe headache of sudden onset is SAH until proved otherwise.
Primary episodic headache disorders
Migraine
Episodic tension type headache
Cluster headache and trigeminal autonomic cephalagias
Primary frequent (chronic daily) headache disorders

Transformed migraine
Chronic tension type headache
Dr. Chan Pang Fai
New daily persistent headache
Combination headache
Hemicranias continua/chronic paroxysmal hemicrania
Secondary headaches
Headache secondary to disorders of the:
Skull (Paget disease, mastoiditis, secondary malignancy)
Ears (otitis media, otitis externa)
Eyes (glaucoma, strabismus, ocular strain, iritis, refractive errors)
Nose and nasal sinuses (acute or chronic sinusitis)
Teeth (tooth abscess, malocclusion)
Cervical spine (cervical spondylosis)
Cranial nerves (herpes zoster, occipital neuralgia)
Headache secondary to:
Intracranial vascular disorders (venous sinus thrombosis, ruptured aneurysm,
cerebral haemorrhage, subarachnoid haemorrhage, extradural/subdural
haematoma)
Extracranial vascular disorders (temporal arteritis, carotid artery or vertebral
artery dissection, cranial arteritis or carotidynia)
Disorders of intracranial pressure (raised intracranial pressure or low
cerebrospinal fluid pressure, e.g. post-lumbar puncture leak, benign intracranial
hypertension/pseudotumour cerebri (sometimes linked to drugs: tetracyclines,
nitrofurantoin, OCPs, vitamin A preparations)
Intracranial tumours (cerebral tumour, pituitary tumour)
Intracranial infections (encephalitis or meningitis or intracranial abscess)
Headache attributable to:
Generalized infection (respiratory tract infection, typhoid, malaria)
Medication (alcohol; analgesics (rebound): aspirin, codeine; antibiotics and
antifungals; antihypertensives: methyldopa, beta-blockers, hydralazine,
reserpine calcium-channel blockers; caffeine; corticosteroids; cyclosporine;
dypyridamole; ergotamine; H2-antagonists; MAOI; nicotine; nitrazepam; nitrous
oxide; NSAIDs; oral contraceptives; PDEs inhibitors: sildanafil, tadelafil; retinoids;
sympathomimetics; theophylline; vasodilators: nitrates, calcium-channel
blockers)
Hypertension
Sleep apnoea
Endocrine disorders (Cushing’s syndrome, Conn’s syndrome, Addison’s disease,
Dr. Chan Pang Fai
thyroid disorders: hypothyroidism and hyperthyroidism, hypoglycaemia)
Anaemia
Post-traumatic headache
Psychogenic disorder: depression, anxiety
Hypnic headache: primarily in the elderly
Age-related causes of headache

Children
Intercurrent infections
Psychogenic
Migraine
Meningitis
Post-traumatic
Adults, including middle age
Migraine
Cluster headache
Tension
Cervical dysfunction
Subarachnoid haemorrhage
Combination
Elderly
Cervical dysfunction
Cerebral tumour
Temporal arteritis
Neuralgias
Paget’s disease
Glaucoma
Cervical spondylosis
Subdural haemorrhage
Red flags for headache

Sudden onset
Severe and debilitating pain
Fever
Rash
Vomiting
Disturbed consciousness
Dr. Chan Pang Fai
Worse with bending or coughing
Maximum in morning
Pressing visual disturbances and papilloedema
Neurological symptoms or signs including meningism
Abnormal vital signs
Young obese female: ? on medication
‘new’ in elderly > 50 years
Tender, poorly pulsatile cranial arteries
Red flags for headache in children

Persistent
Present first thing in morning
Wakes child at night
No past history
No family history
Associated poor health
Associated neurological symptoms
Unilateral localisation
Investigations
CBP: anaemia, leucocytosis with bacterial infection
ESR: temporal arteritis
Other blood tests for suspected endocrine disorders
Radiography:
CXR: if suspected intracerebral malignancy
X-ray C-spine: cervical spondylosis
SXR: if suspected brain tumour, Paget’s disease, deposits in skull
X-ray sinuses: sinusitis
CT: brain tumour, cerebrovascular accidents, SAH
Radioisotope (technetium-99m) scan: to localize specific tumours and
haematoma
MRI: better definition of intracerebral structures, detects intracranial vasculitis
in temporal arteries abut not as sensitive for detecting bleeding
Lumbar puncture: meningitis, suspected SAD (only if CT normal)
References
Diagnosis Headache. Australian family physician Volume 34, Number 8, August 2005.
Dr. Chan Pang Fai
25) Heart murmur

 Acquired heart disease, as well as congenital, can be identified later in lift,
especially in the case of patients who perform strenuous physical activities.
 All diastolic murmurs are pathologic and occur due to aortic or pulmonary
insufficiency, stenosis, and changes in outflows through mitral or tricuspid
valves.
 Innocent murmurs occur in 50% or more of children. They are more often
present in the febrile children. Charateristically:
 Normal heart sound
 Low intensity, quieter sitting up
 Musical quality, usually ejection mid-systolic
 Localized to a small precordial area
 No other symptoms or signs of heart disease
 Consider significant serious murmurs in children if:
 Age less than 12 months
 Other congenital abnormalities
 Symptoms and signs of cardiac dysfunction e.g. cyanosis, dyspnoea,
syncope, arrhythmia, hypertension, intolerance to physical activity, chest
pain
 Feeding difficulties or poor growth

 In elderly, asymptomatic patients with soft, short ejection systolic murmurs and
well-heard second sounds are unlikely to have severe aortic stenosis, and do not
require echocardiography.
 Echocardiography should be requested in patients with a loud murmur in the
aortic area, with any suggestion of exertional symptoms or clinical signs of heart
failure.
 There is an association of hypercholesterolaemia with aortic valve sclerosis.
Ejection systolic murmur
Innocent
Tachycardia
Pregnancy
Aortic sclerosis
Aortic stenosis
Dr. Chan Pang Fai
Pulmonary stenosis
HOCM
Ventricular septal defect
Atrial septal defect
Pansystolic murmur
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Mitral valve prolapsed (late systolic murmur ± midsystolic click)
Early diastolic murmurs

Aortic regurgitation
Pulmonary regurgitation
Graham steell murmur (pulmonary regurgitation secondary to pulmonary
hypertension resulting from mitral stenosis)
Mid-diastolic murmurs
Mitral stenosis
Carey Coombs’ murmur (rheumatic fever with thickening of the mitral valve leaflets)
Aortic regurgitation (Austin Flint murmur: fluttering of the anterior mitral valve cusp
caused by the regurgitant stream)
Continuous murmurs
Patent ductus arteriosus
Arteriovenous fistula
Ruptured sinus of valsalva
Investigations
CXR: in children, a cardiothoracic index equal to or below 0.6 is considered normal,
changes in cardiac silhouette can suggest pathologies in the following situations:
boot-shaped heart with low pulmonary flow (tetralogy of Fallot); “snowman”
appearance (supracardiac anomalous drainage of pulmonary veins); and ovoid shape,
narrow pedicel, pulmonary overflow (transposition of the great arteries); ribs
notching in the lower border (coarctation of the aorta)
ECG
Echocardiography
Dr. Chan Pang Fai
CBP: anaemia caused hyperkinetic state
References
Evaluation of Systolic Murmur in the Elderly. The Hong Kong Practitioner Volume 25,
March 2003.
Assessment of Heart Murmurs in childhood. Journal de Pediatria Volume 79,
Supplement 1, 2003.
Dr. Chan Pang Fai
26) Hip, buttock and groin pain

 Pain in the hip, buttock, groin and upper thigh tend to be interrelated.
 Most pain in the buttock has a lumbosacral origin.
 Pain originating from disorders of the lumbosacral spine (commonly) and the
knee (uncommonly) can be referred to the hip region, while pain from the hip
joint may be referred commonly to the thigh and the knee.
 Disorders of the abdomen, retroperitoneal region and pelvis may cause hip and
groin pain, sometimes mediated by irritation of the psoas muscle.
 Children can suffer from a variety of serious disorders of the hip such as
developmental dysplasia of the hip/congenital dislocation of the hip (DDH),
Perthes’ disease, tuberculosis, septic arthritis, slipped capital femoral epiphysis
(SCFE) and inflammatory arthritis all of which demand early recognition and
management.
 The commonest cause of hip and buttock pain presenting in general practice is
referred pain from the lumbosacral spine and the sacroiliac joints.
 Trauma and overuse injuries from sporting activities are also common causes of
muscular and ligamentous strains around the buttock, hip and groin.
 The hip joint is a common target of osteoarthritis.
 The major triad of serious disorders – cardiovascular, neoplasia and severe
infections are applicable to the hip, buttock and groin.
 Any adolescent with a limp or knee pain should have X-rays of both hips.
 The most common problem in the little athlete is pain or discomfort in the
region of the iliac crest or anterior or superior iliac spines, usually associated
with traction apophysitis or with acute avulsion fractures.
 The impacted subcapital fractured femoral neck can often permit
weight-bearing by an elderly patient. No obvious deformity of the leg is present.
Radiographs are therefore essential of all painful hips in the elderly.
 Consider avascular necrosis in those at risk: corticosteroid use, SLE, sickle cell
disease, past hip fracture, pregnancy, alcoholic liver disease.
Probability diagnosis
Traumatic muscular strains
Referred pain from spine
Osteoarthritis of hip
Dr. Chan Pang Fai
Serious disorders not to be missed
Cardiovascular: buttock claudication (aortoiliac occlusion)
Neoplasia: metastatic carcinoma, myeloma, lymphoma, sarcoma
Osteoid osteoma
Septic infections: septic arthritis, osteomyelitis, tuberculosis, pelvic and abdominal
infections (pelvic abscess, PID)
Childhood disorders: DDH, Perthes’ disease (avascular necrosis), slipped femoral
epiphysis, transient synovitis (irritable hip), juvenile chronic arthritis, stress
fractures of the femoral neck, pathological fractures through bone cyst
Pitfalls (often missed)
Polymyalgia rheumatica
Fractures: stress fractures femoral neck, subcapital fractures, sacrum, pubic rami
Avascular necrosis femoral head
Sacroiliac joint disorders: inflammation of sacroilitis or mechanical dysfunction
Osteitis pubis
Inguinal or femoral hernia
Greater trochanter pain syndrome
Bursitis or tendonitis: gluteus medius tendonitis, trochanteric bursitis, ischial bursitis
Femoroacetabular and pincer impingement
Osteitis pubis
Neurogenic claudication
Chilblains
Haemarthrosis (e.g. haemophilia)
Paget’s disease
Nerve entrapment (Meralgia paraesthetica: sciatica ‘hip pocket nerve’, obturator,
lateral cutaneous nerve thigh)
Depression
Spinal dysfunction
Red flags to potentially serious hip conditions

Swelling, redness, very limited joint motion
Pain, fever, systemic features (in absence of trauma)
Neurological changes
Rapid joint swelling after trauma
Constant localized pain unaffected by movement
Dr. Chan Pang Fai
Investigations
Serological tests
RF
CBP
ESR
CRP
Radiological
AP X-ray of pelvis showing both hip joints
Lateral X-ray (“Frog” lateral best in children)
X-ray L-S spine and SIJs
USG: septic arthritis, DDH, osteomyelitis abscess
CT: hip joints, pelvis, L-S spine
MRI: stress fracture, early avascular necrosis, early osteomyelitis, labral tears of
hip joint, metastasis, soft tissue tumours
Isotope bone scan: whole body metastasis
Needle aspiration of joint fluid for culture: septic arthritis
References
Hip Pain: A Focus of the Sporting Population. Australian Family Physician Volume 36,
No. 6, June 2007
Dr. Chan Pang Fai
27) Hirsutism and hypertrichosis

 Hirsuties is growth in the female of excess, coarse, terminal pigmented hair in
androgen-dependent sites, namely in a male sexual pattern.
 Hirsutism is a common disorder affecting up to 8 percent of women.
 Hair growth varies widely among women, and distinguishing normal variations
of hair growth from hypertrichosis and true hirsutism is important.
 Most cases are due to idiopathic hirsutism, which may follow racial or familial
factors, or to variant of the polycystic ovarian syndrome.
 Routine investigation is not required unless there are other features of
virilisation (development of male characteristics in women). Virilization occurs
in less than 1 percent of patients with hirsutism.
 It is important to exclude adrenal or ovarian pathology.
 Hirustism of reasonably sudden onset is an important marker for serious
underlying pathology.
 Appropriate investigations include pelvic ultrasound to diagnose polycystic
ovaries and serum testosterone, 17-hydroxoprogesterone and
dehydroepiandrostenedione (DHEA), which indicates an adrenal cause of
androgen excess if elevated.
 For patients with severe hirsutism and regular menses, serum testosterone,
DHEA and early morning 17-hydroxyprogesterone levels should be measures.
 If menses is irregular, thyroid function, measure follicle stimulating hormone
(FSH), luteinizing hormone (LH), and serum prolactin.
 Hypertrichosis is the increased growth of fine vellus or downy hair over the
entire body. The cause is generally unknown or familial. An important cause of
secondary hypertrichosis is drugs. It is also associated with an underlying
neoplasia, such as carcinoma of the stomach, when it is termed hypertrichosis
lanuginose acquisita or malignant down.
Hirsutism
Familial or idiopathic
Drugs: anabolic steroids, danazol, metoclopramide, methyldopa, phenothiazines,
progestins, reserpine, testosterone, OCPs
Excess androgen secretion by the ovary:
PCOS
Tumours: arrhenoblastoma is the most common
Dr. Chan Pang Fai
Excess androgen secretion by adrenal glands:
Congenital adrenal hyperplasia
Cushing’s syndrome
Tumours
Hypertrichosis
Unknown or familial
Drugs: phenytoin, minoxidial, cyclosporine, corticosteroids, diazoxide, anabolic
steroids, penicillamine, psoralens, streptomycin
Neoplasia: stomach cancer
Anorexia nervosa
Menopause
Starvation
Hypothyroidism
Porphyrias
Epidermolysis bullosa
Dermatomyositis
Severe head injury
Rare syndromes: e.g. Hurler’s syndrome, fetal alcohol syndrome, trisomy 18
syndrome, Cornelia de Lange syndrome
Investigations
Testosterone
17-hydroxyprogesterone
LH/FSH
Prolactin
TFT
DHEAS
Cortisol
ACTH
USG abdomen and pelvis
CT abdomen
Dr. Chan Pang Fai
Evaluation of Hirsutism
FIGURE 1. Algorithm showing the evaluation of hirsutism. (ACTH = adrenocorticotropic hormone; CAH
= congenital adrenal hyperplasia; DHEAS = dehydroepiandrosterone sulfate; PCOS = polycystic ovary
syndrome; 17-OHP = 17 alpha-hydroxyprogesterone)
References
Evaluation and Treatment of Women with Hirsutism. American Family Physician
Volume 67, No. 12, June 15, 2003.
Dr. Chan Pang Fai
28) Impotence (Erectile dysfunction)

 Erectile dysfunction is the inability to achieve or maintain an erection of
sufficient quality for satisfactory intercourse. It doesn’t refer to ejaculation,
fertility or libido.
 Erectile dysfunction is a common problem. US data shows the prevalence to be
39% of males at 40 years and 67% of males aged 70.
 Only 10% of men with erectile dysfunction having discussed their problem with
their doctor.
Psychogenic causes: stress, depression, generalized anxiety, marital disharmony,
performance anxiety
Neurogenic causes: disorders affecting the parasympathetic sacral spinal cord (e.g.
multiple sclerosis), diabetes
Vascular: hypertension, ischaemic heart disease, diabetes mellitus
Hormone disorder: androgen deficiency, hypothyroidism, hyperprolactinaemia
Drug: alcohol, cocaine, nicotine, beta-blockers, thiazide diuretics, antidepressants,
antipsychotics, H2-blockers, cholesterol lowering drugs
Ageing
Unknown
Investigations
Testosterone: androgen deficiency
TSH: hypothyroidism
Prolactin: hyperprolactinaemia
LH and progesterone: hypogonadism
FBG: diabetes
LFT and GGT: alcoholic
RFT
Ferritin: haemochromatosis may cause hypogonadism in Anglo-Celtic patients
References
Erectile Dysfunction. Australian Family Physician Volume 32, No. 6, June, 2003.
Dr. Chan Pang Fai
29) Jaundice
 Jaundice is defined as a serum bilirubin level exceeding 17µmol/L2.
 Clinical jaundice manifests only when bilirubin level exceeds 50µmol/L2.
 The three major categories of jaundice are: obstructive (extrahepatic or
intrahepatic), hepatocellular and haemolysis.
 The most common causes of jaundice recorded in general practice population
are (in order) viral hepatitis, gallstones, carcinoma of pancreas, cirrhosis,
pancreatitis and drugs.
 Viral hepatitis A, B or C accounts for the majority of cases of jaundice.
 In the middle-aged and elderly group, a common cause is obstruction from
gallstones or cancer.
 Malignancy must always be suspected, especially in the elderly patient and
those with a history of chronic active hepatitis. Metastatic carcinoma must be
kept in mind.
 A patient who has the classic Charcot’s triad of upper abdominal pain, fever (and
chills) and jaundice should be regarded as having ascending cholangitis until
proved otherwise.
 Wilson’s syndrome must be considered in all young patients with acute
hepatitis.
 Gilbert’s syndrome is worth considering, especially as it is the commonest form
of unconjugated hyperbilirubinaemia. It affects at least 3% of the population.
 Cardiac failure can present as jaundice with widespread tenderness under the
right costal margin. It can be insidious in onset or manifest with gross acute
failure.
 The laboratory work-up should begin with a urine test for bilirubin, which
indicates that conjugated hyperbilirubinaemia is present.
 All patients with jaundice should be tested for hepatitis B surface antigen
(HBsAg).
 If the complete blood count and initial tests for liver function and infectious
hepatitis are unrevealing, the work-up typically proceeds to abdominal imaging
by ultrasonography or computed tomographic scanning.
Prehepatic causes of unconjugated hyperbilirubinaemia
Haemolysis (e.g. hereditary spherocytosis, glucose-6-phosphate dehydrogenase
deficiency (G6PD), autoimmune, drugs, sickle cell disease, thalassaemias)
Dr. Chan Pang Fai
Haematoma resorption
Intrahepatic causes of unconjugated hyperbilirubinaemia
Gilbert syndrome
Crigler-Najjar syndrome
Intrahepatic causes of conjugated hyperbilirubinaemia

Viral hepatitis (hepatitis A, B, C, EBV)
Alcohol causes cholestasis, fatty liver, hepatitis and cirrhosis
Drugs: acetaminophen/paracetamol, penicillins, oral contraceptives, chlorpromazine,
oestrogen or anabolic steroids
Pregnancy: acute fatty liver of pregnancy
Severe infections (e.g. septicaemia, ascending cholangitis, fulminant hepatitis,
HIV/AIDS)
Autoimmune disorders (e.g. primary biliary cirrhosis, primary sclerosing cholangitis)
Hepatocelluar carcinoma
Dubin-Johnson syndrome
Roto’s syndrome
Haemochromatosis
Wilson’s syndrome
Reye’s syndrome
Sarcoidosis
Parenteral nutrition
Extrahepatic causes of conjugated hyperbilirubinaemia

Intrinsic to the ductal system
Gallstones
Surgical strictures
Infection (CMV, cryptosporidium infection in patients with acquired
immunodeficiency syndrome)
Intrahepatic malignancy
Cholangiocarcinoma
Extrinsic to the ductal system

Extrahepatic malignancy (pancreas, lymphoma)
Pancreatitis
Dr. Chan Pang Fai
Drugs that can cause jaundice
Haemolysis
Methyldopa
Hepatocellular damage
Dose-dependent
Paracetamol
Salicylates
Tetracycline
Dose-independent
Anaesthetics (e.g. halothane)
Antidepressants (e.g. MAOIs)
Antiepileptics (e.g. phenytoin, sodium valproate, carbamazepine)
Antibiotics (e.g. penicillins, sulphonamides)
Antimalarials (e.g. Fansidar)
Antituberculosis (e.g. isoniazid)
Anti-inflammatories (e.g. NSAIDs, various)
Carbon tetrachloride
Cardiovascular (e.g. amiodarone, methyldopa), perhexilene)
Statins (e.g. simvastatin)
Cholestasis
Antithyroid drugs
Chlorpromazine
Erythromycin estolate
Penicillins, esp. flucloxacillin
Gold salts
Oral contraceptive/oestrogens
Synthetic anabolic steroids
Hypoglycaemic drugs (e.g. chlorpropamide)
Amitriptyline
Others
Allopurinol
Cimetidine (aggravated by alcohol)
Cytotoxics (e.g. methotrexate, azathioprine)
Etretinate
Dr. Chan Pang Fai
Hydralazine
Nitrofurantoin
Vitamin A (mega dosage)
Various complementary medicines, e.g. herbal agents
Investigations
Urinalysis for bilirubin
LFT including aspartate transaminase (AST), alanine transaminase (ALT), γ-glutamyl
transpeptidase (GGT), alkaline phosphatase levels (ALP), direct and indirect bilirubin
(with alcohol-induced damage, the ratio of AST to ALT is usually greater than 1,
whereas infectious causes of hepatitis typically cause greater elevation in ALT than
AST)
CBP, reticulocyte count: anaemia with raised reticulocyte in haemolysis
Anti-HAV IgM, HBsAg, anti-HBc
Viral serology for EBV and CMV
Autoimmune markers: antinuclear, smooth muscle (autoimmune chronic active
hepatitis), liver-kidney microsomal antibodies (autoimmune chronic active hepatitis),
anti-mitochondrial antibody (primary biliary cirrhosis), antineutrophil cytoplasmic
antibodies (primary sclerosing cholangitis).
Amylase: pancreatitis
CEA (carcinoembryonic antigen): to detect liver secondaries, especially colorectal
AFP (alpha-fetoprotein): elevated in hepatocelluar carcinoma; mild elevation with
acute or chronic liver disease (e.g. cirrhosis)
Serum cerulopasmin level: low in Wilson’s syndrome
AXR: shows up to 10% of gallstones only
USG: the most useful investigation for detecting gallstones and dilatation of the
common bile duct; also detects liver metastases and other diffuse liver diseases
CT: for diagnosis of enlargement of the head of the pancreas and other pathology;
indicated if USG unsatisfactory
PTC (percutaneous transhepatic cholangiography)
ERCP (endoscopic retrograde cholangiopancreatography): PTC and ERCP (best)
determine the cause of the obstruction
MRCP (magnetic resonance cholangiography): provides non-invasive planning for
obstructive jaundice
HIDA scintiscan: useful in diagnosis of acute cholecystitis
Liver biopsy: autoimmune hepatitis or biliary tract disorders (e.g. primary biliary
cirrhosis, primary slcerosing cholangitis) or cirrhosis
Dr. Chan Pang Fai
Clinical Jaundice in Adults
References
Jaundice in the Adult Patient. American Family Physician Volume 69, No. 2, January
15, 2004.
Dr. Chan Pang Fai
30) Knee pain

 A rapid onset of painful knee swelling after injury indicates haemarthrosis.
 Swelling over 1-2 days after injury indicates traumatic synovitis.
 Acute spontaneous inflammation of the knee may be a part of a systemic
condition such as rheumatoid arthritis, rheumatic fever, gout, pseudogout, a
spondyloarthropathy, Lyme disease and sarcoidosis.
 Disorders of the lumbosacral spine and of the hip joint refer pain to the region
of the knee joint.
 The condition known as anterior knee pain is the commonest type of knee pain
and accounts for at least 11% of sports-related musculoskeletal problems. The
prime cause of this is patellofemoral dysfunction pain.
 A UK study has highlighted the fact that the commonest cause of knee pain is
simple ligamentous strains and bruises due to overstress of the knee or other
minor trauma.
 The most common overuse problem of the knee is the patellofemoral joint pain
syndrome (chondromalacia patellae).
 Osteoarthritis of the knee, especially in the elderly, is a very common problem.
It may arise spontaneously or be secondary to previous trauma with associated
internal derangement and instability.
 Neoplasia in the bones around the knee is relatively uncommon but still needs
consideration. The commonest neoplasias are secondaries from the breast, lung,
kidney, thyroid and prostate.
 Septic arthritis and infected bursitis are prone to occur in the knee joint,
especially following contaminated lacerations and abrasions.
 Inflammatory disorders such as spondyloarthropathies, sarcoidosis,
chondrocalcinosis, gout and juvenile chronic arthritis have to be considered in
the differential diagnosis.
 The presence of a spontaneous effusion demands careful attention because if
could represent a rheumatic disorder or conditions such as osteochondritis
dissecans or osteonecrosis of the femoral condyle and perhaps a subsequent
loose body in the joint.
 Children competing in sporting activities, especially running and jumping, are
prone to overuse injuries such as the patellofemoral pain syndrome, traumatic
synovitis of the knee joint and Osgood-Schlatter disease.
 Always think of an osteoid osteoma in a young boy with severe bone pain in a
leg that responds nicely to paracetamol or NSAIDs.
Dr. Chan Pang Fai
 Radiographs should be obtained in patients with isolated patellar tenderness or
tenderness at the head of the fibula, inability to bear weight or flex the knee to
90 degrees, or age greater than 55 years.
Ligamentous strains and sprains
Traumatic synovitis
Osteoarthritis
Patellofemoral syndrome/chondromalacia patellae/jogger’s knee/runner’s
knee/cyclist’s knee
Prepatellar bursitis
Patella tendonitis/patella tendinopathy (Jumper’s knee)
Other overuse syndromes: semimembranous tendonitis/bursitis, biceps femoris
tendonitis, quadriceps tendonitis/rupture, popliteus tendonitis, iliotibial band friction
syndrome, the hamstrung knee, synovial plica syndrome, infrapatellar fat-pad
syndrome, prepatellar bursitis/housemaid’s knee/carpet layer’s knee, infrapatellar
bursitis/clergyman’s knee
Gout
Referred pain from back or hip
Ruptured popliteal cyst
Acute cruciate ligament tear
Meniscal tear
Neoplasia: primary in bone (osteoid osteoma, osteosarcoma, Ewing’s tumour),
metastases
Severe infections: septic infections, tuberculosis
Rheumatoid arthritis
Juvenile chronic arthritis
Rheumatic fever
Foreign bodies
Intra-articular loose bodies
Osteochondritis dissecans
Osteonecrosis
Osgood-Schlatter disorder (traction apophysitis, commonest age 10-14years)
Fractures around knee
Pseudogout (chondrocalcinosis)
Spondyloarthropathy
Vascular disorders: deep venous thrombosis, superficial thrombophlebitis
Dr. Chan Pang Fai
Paget’s disease
Sarcoidosis
Anterior knee pain
Patellofemoral syndrome
Osteoarthritis
Osgood-Schlatter lesion
Patellar tendonopathy
Osteonecrosis
Lateral knee pain

Osteoarthritis of lateral compartment of the knee
Lesions of the lateral meniscus
Iliotibial band tendonitis
Posterior cruciate ligament injury
Medial knee pain

Osteoarthritis of medial compartment of knee
Medial collateral ligament sprain
Lesions of the medial meniscus
Anserinus bursitis/pes anserine bursitis
Synovial plica syndrome
First decade (0-10 years)

Infection
Juvenile chronic arthritis
Second decade (10-20 years)

Patellar tendonitis
Subluxation/dislocation of patella
Slipped femoral epiphysis (referred pain)
‘Hamstrung’ knee (in young active sportspeople caused by a failure to warm up
properly and stretch the hamstring muscles, which become tender and tight during
the growth spurt)
Osteochondritis dissecans
Dr. Chan Pang Fai
Osgood-Schlatter disorder (tibial apophysitis)
Anserinus tendonitis (localized tenderness over the medial tibial condyle where the
tendons of the Sartorius, gracilis and semitendinosus insert into the bone, common
cause of knee pain in the middle aged or elderly, especially the overweight woman)
Third decade (20-30 years)

Bursitis
Mechanical disorders
Synovial plica syndrome
Fourth and fifth decades (30-50 years)

Cleavage tear of medial meniscus
Radial tear of lateral meniscus
Sixth decade and older (50 years and over)

Osteoarthritis
Osteonecrosis
Paget’s disease (femur, tibia or patella)
Anserinus bursitis/pes anserine bursitis
Chondrocalcinosis and gout
Osteoarthritis of hip (referred pain)
Investigations
RF
ANA
HLA B27
CBP: septic arthritis
ESR: septic arthritis, rheumatoid arthritis
Blood culture: suspected septic arthritis
X-ray
Intercondylar view/posteroanterior tunnel view (osteochondritis dissecans,
loose bodies)
Tangential or skyline view (suspected patella pathology)
Oblique view (to define condyles and patella)
Weight-bearing views (degenerative arthritis)
Bone scan: suspected tumour, stress fracture, osteonecrosis, osteochondritis
dissecans
Dr. Chan Pang Fai
MRI: excellent for diagnosing cartilage and menisci disorders and ligament damage
USG: good for assessment of patellar tendon, soft tissue mass, fluid collection,
Baker’s cyst and bursae
CT: useful for complex fractures of tibial plateau and patellofemoral joint special
dysfunction
Arthroscopy
Knee aspiration for culture and crystal examination
Ottawa knee rules for X-ray of an injured knee

 Patient aged 55 years or more
 Isolated tenderness of the patella
 Tenderness at the head of the fibula
 Inability to flex to 90°
 Immediate inability to weight bear
Ottawa knee rules for children with knee pain

 Isolated tenderness of the patella (no bone tenderness of the knee other than
the patella)
 Tenderness at the head of the fibula
 Inability to flex to 90°
 Inability to bear weight both immediately and in the emergency department
References
Evaluation of Patients Presenting with Knee Pain. American Family Physician Volume
68, September 1, 2003.
Evaluating Patients with Acute Knee Pain: A Review. American Family Physician, June
1, 2004.
Dr. Chan Pang Fai
31) Loin pain

Kidney diseases
Abscess and perinephric abscess
IgA nephropathy
Kidney cancer
Kidney infection, pyelonephritis
Kidney stone
Medullary Sponge Kidney
Nephritis
Polycystic kidney disease
Renal vein thrombosis
Pain referred from vertebral column
Cholecystitis
Cholelethiasis
Diverticulitis
Enlarged spleen and spleen inflammation
Lumbar hernia
Prostate cancer
Shingles
Ulcerative colitis
Investigations
CBP: anaemia in chronic renal failure, raised WBC in infection
RFT: renal diseases
LFT: gallbladder disease
PSA: CA prostate
Urinalysis and urine culture: urinary tract infection
KUB: renal stone
X-ray spine: pain referred from vertebral column
IVU: ureteric stones
USG: kidney and gallbladder diseases
CT: major advantage of demonstrating many other possible causes of loin pain in
patients that do not have ureteric stones
Dr. Chan Pang Fai
References
http://www.wrongdiagnosis.com/symptoms/loin_pain/causes.htm
Investigation of Loin Pain. Imaging Volume 17, 19-33, 2005.
Dr. Chan Pang Fai
32) Low back pain

 Low back pain accounts for at least 5% of general practice presentations.
 Approximately 85% of the population will experience back pain at some stage of
their lives.
 At least 50% of these people will recover within 2 weeks and 90% within 6
weeks. 2-7% develops chronic pain.
 The most common cause of back pain is minor strain to muscles and/or
ligaments, but people suffering from this type of back pain usually do not seek
medical treatment as most of these soft tissue problems resolve rapidly.
 The main cause of back pain presenting to the doctor is dysfunction of the
intervertebral joints of the spine due to injury, also referred to as mechanical
back pain (70%). The term mechanical pain embraces musculoskeletal strain,
discogenic and posterior ligament, and facetogenic dysfunction/pain.
 The second most common cause of back pain is spondylosis (osteoarthritis and
degenerative back disease) (10%). This problem, and one of its complications,
spinal canal stenosis, is steadily increasing along with the ageing population.
 Mechanical dysfunction and osteoarthritis can develop simultaneously.
 L5 and S1 nerve root lesions represent most of the causes of sciatica presenting
in general practice.
 An intervertebral disc prolapse has been proven in only 6-8% of cases of back
pain.
 In theory, any structure with a nociceptive nerve supply may be a source of pain.
Such structures include the ligaments, fascia, muscles of the lumbosacral spine,
intervertebral joints, facet joints, dura mater and sacroiliac joint.
 Acutally, pain can theoretically arise from any innervated structure in the region
of the spine. It can be neurogenic, spondylogenic, viscerogenic, vasculogenic or
rarely psychogenic.
 It is important to consider malignant disease, especially in an older person. It is
also essential to consider infection such as acute osteomyelitis and tuberculosis.
 For pain or anaesthesia of sudden onset, especially when accompanied by
neurological changes in the legs, consider cauda equine compression due to a
massive disc prolapse and also retroperitoneal haemorrhage.
 The inflammatory disorders must be kept in mind, especially the
spondyloarthropathies, which include psoriatic arthropathy, ankylosing
spondylitis, Reiter’s syndrome, inflammatory bowel disorders and reactive
arthritis. The spondyloarthropathies are more common than appreciated and
Dr. Chan Pang Fai
must be considered in the younger person presenting with features of
inflammatory back pain.
 If malignant disease or osteomyelitis is suspected but an X-ray is normal, a
radionuclide scan should detect the problem.
 For the young women with upper lumbar pain, especially if she is pregnant, the
possibility of a urinary tract infection must be considered.
 Mechanical problems from computer use, physical activity, or heavy backpacks
do not appear to be associated with back pain in school-age children. Low back
pain is more common in school-age children with high levels of psychosocial
difficulties, conduct problems, or other somatic disorders.
 Studies of children and adolescents presenting with a primary complaint of back
pain in a nonemergency setting have successfully identified pathology in a high
number of patients.
 Common diagnoses in children or adolescents with back include nonspecific
pain or muscle strain, herniated disk, spondylolysis, scoliosis, and
Scheuermann’s kyphosis. Less common causes include tumour, infection, and
sickle cell crisis.
 Plan X-rays of the lumbar spine are not routinely recommended in acute
non-specific LBP in the absence of ‘red flags’ as they are of limited diagnostic
value and no benefits in physical function are observed. X-rays may appear
normal in disc prolapse.
 Children and adolescents without significant physical findings, short duration of
pain, and a history of minor injury can be treated conservatively without
radiographic or laboratory studies.
 Back pain attributed to a work injury is not, in itself, an indication for imaging at
the first visit.
 Screening tests (plan X-ray, urine dipstick, ESR, CRP, ALP, PSA in males > 50 years)
are most important for the patient presenting with chronic back pain when
serious disease such as malignancy, osteoporosis, infection or
spondyloarthropathy must be excluded. However, plan X-ray can miss pathology
in the early stages of malignancy as they require 50-75% of focal bone loss in
cancellous bone to be visible on the anteroposterior (AP) view.
 If clinical suspicion is sufficiently high, it may be necessary to proceed directly to
advanced imaging. If MRI is not readily available, or if the cost is prohibitive, CT
may be adequate.
 Diagnostic imaging of the spine has a high rate of abnormal findings in
asymptomatic persons. In studies of lumbar spine MRI evaluation of
Dr. Chan Pang Fai
asymptomatic adults, herniated disks in 20 to 80%, degenerative disks in 46 to
93%, and annular tears in 14 to 56%. Therefore, imaging should be used in
carefully selected patients and interpreted with appropriate clinical correlation.
Vertebral dysfunction especially facet joint and disc
Musculoligamentous strain/sprain (70%)
Spondylosis (degenerative OA 10%)
Spondyloarthropathies (ankylosing spondylitis, Reiter’s syndrome, psoriasis, bowel
inflammation, juvenile rheumatoid arthritis)
Vertebral fracture: osteoporotic compression fracture (4%), slipped vertebral
apophysis (fracture of the vertebral growth plate), spondylolysis (fracture of the pars
interarticularis)
Sacroiliac dysfunction
Herniated disks (4%)
Spinal stenosis (3%)
Spondylolisthesis (2%)
Scheuermann’s disease in adolescents: osteochondrosis with abnormality of the
vertebral epiphyseal growth plates
Scoliosis
Severe infections (osteomyelitis, epidural abscess, diskitis, tuberculosis, pelvic
abscess/PID)
Cauda equina compression
Neoplasia (0.7%) (Paget’s disease, myeloma, metastases in adults; osteoid osteoma,
osteoblastoma, eosinophilic granuloma, Ewing’s sarcoma, neurofibroma,
astrocytoma, leukaemia and osteogenic sarcoma in children)
Claudication (vascular, neurogenic)
Cardiovascular (ruptured aortic aneurysm, retroperitoneal haemorrhage)
Prostatitis
Endometriosis
Pelvic inflammatory disease
Renal organs: nephrolithiasis, Urinary tract infection including pyelonephritis
Aortic aneurysm
Gastrointestinal system: pancreatitis, cholecystitis, peptic ulcer
Shingles
Depression
Sickle cell crisis
Dr. Chan Pang Fai
Red flag pointers to serious low back pain conditions
Age > 50years
History of cancer
Temperature > 37.8°C
Constant pain – day and night
Weight loss
Symptoms in other systems, e.g. cough, breast mass
Significant trauma
Features of spondyloarthropathy, e.g. peripheral arthritis
Neurological deficit
Drug or alcohol abuse
Use of anticoagulants
Use of corticosteroids
Use of immunosuppression
Known to have osteoporosis
No improvement over 1 month
Possible cauda equina syndrome (saddle anaesthesia, recent onset bladder
dysfunction, severe or progressive neurological deficit)
Yellow flags pointers to identify psychosocial and occupational factors that may
increase the risk of chronicity in people presenting with acute back pain
Abnormal illness behaviour
Compensation issues
Unsatisfactory restoration of activities
Failure to return to work
Unsatisfactory response to treatment
Treatment refused
Atypical physical signs
Investigations
Screening tests
X-ray L-S spine (AP and later, oblique views for spondylolysis, and pelvis):
 the notion that radiological abnormalities in anatomy can be invoked as the
cause of back pain has been challenged by several studies
 the most common of these abnormalities are the degenerative changes
including spondylosis/osteophytes, spondylolysis, disc calcification, facet
joint arthrosis and subluxation, their incidence is similar in patients with
Dr. Chan Pang Fai
back pain and in asymptomatic controls
 a relationship has been found between back pain and the radiological
findings of compression fractures
 there is a weak association between pain and spondylolisthesis in women,
but not in men
 there is a weak association between pain and multiple disc degeneration in
the lumbar spine, but not the thoracic spine, the association with the
lumbar spine weakens with age as the prevalence of degenerative changes
increases
Urine dipstix
ESR/CRP
ALP
PSA (in males > 50 years)
Specific disease investigation

Peripheral arterial studies: peripheral vascular disease
HLA-B27 antigen: ankylosing spondylitis (+ve in over 90% of cases but 10% of
population are positive) and Reiter’s syndrome
Serum electrophoresis: multiple myeloma
PSA: CA prostate
Brucella agglutination test
Blood culture: pyogenic infection and bacterial endocarditis
Bone scan: inflammatory or neoplastic disease and infection (e.g. osteomyelitis)
Tuberculosis studies
X-rays of shoulder and hip joint
CT: CT scan is superior to X-rays at defining bony and soft tissues abnormalities
following trauma
MRI:
 there is a stronger association between chronic low back pain and fissures
in the posterior annulus of the disc demonstrated on MRI
 particularly useful for detecting tumours, infections and disk herniations
Myelography or radiography
Discography
EMG: to screen for leg pain and differentiate neurological diseases from nerve
compression syndromes
Radioisotope scanning
Technetium pyrophosphate scan for SIJ: ankylosing spondylitis
Dr. Chan Pang Fai
Selective anesthetic block of facet joint under image intensification
Selective anesthetic block of medial branches of posterior primary rami and other
nerve roots
References
Evaluation and Treatment of Acute Low Back pain. American Family Physician Volume
75, No. 8, April 15, 2007.
Evaluation of Back Pain in Children and Adolescents. American Family Physician
Volume 76, No. 11, December 1, 2007.
Back Pain – Clinical Assessment. Australian Family Physician Volume 33, No. 6, June
2004.
Diagnostic Imaging for Back Pain. Australian Family Physician Volume 33, No. 6, June
2004.
Dr. Chan Pang Fai
33) Lower urinary tract symptoms in men

 These symptoms can be grouped as voiding symptoms (obstructive: hesitancy,
weak stream, postmicturition dribble, incomplete emptying/urinary retention,
straining) or storage symptoms (irritative: urgency, urge incontinence, frequency,
nocturia, dysuria, suprapubic pain). Irritative symptoms may be caused by a
bladder problem only. Obstructive symptoms are usually caused by the prostate.
 Bladder outlet obstruction can also be caused by bladder neck obstruction and
urethral sphincter spasm.
 Around one third of men will develop urinary tract symptoms, of which the
principal underlying cause is benign prostatic hyperplasia.
 The prevalence of BPH increases with age and one study suggests that the
prevalence is 20% in a 40 years old men and increases to 90% in men in their
seventies.
 It is estimated that the lifetime risk of developing microscopic prostate cancer is
about 30%, developing clinical disease 10%, and dying from prostate cancer 3%.
 The American Urological Association (AUA) recommends urinalysis for all men
presenting with lower urinary tract symptoms. Normal urinalysis findings help
rule out non-BPH causes of the symptoms, such as bladder cancer, bladder
stones, UTI, or urethral strictures.
 Prostate-specific antigen (PSA) levels should be measured in men who have at
least a 10-year life expectancy and who would be a candidate for prostate
cancer treatment. PSA levels correlate with the risk of symptom progression and
prostate volume which may affect the treatment choice, if indicated.
 Urinary cytology should be obtained in men at risk of bladder cancer.
 Routine measurement of serum creatinine levels is not recommended because
BPH does not appear to affect the baseline risk of renal disease.
Benign prostatic hypertrophy/hyperplasia
Detrusor muscle weakness and/or instability
Urinary tract infection
Chronic prostatitis
Calculi
Bladder neck obstruction
Urethral sphincter spasm
Carcinoma of prostate
Dr. Chan Pang Fai
Drugs:
Anticholinergics: Atropine and hyoscine compounds (isopropamide, mazindol,
phenothiazines, dicyclomine, propantheline, other belladonna alkaloids),
Tricyclic antidepressants, Anti-parkinson agents (amantadine, benzhexol,
benztropine, biperiden, orphenadrine, procyclidine), anthihistamines
Beta-adrenoceptor agonists: ephedrine, salbutamol, terbutaline, OTC
preparations with sympathomimetics including ephedrine
Diuretics: increased urine production
Opiates: impaired autonomic function
Neurological disease caused neurogenic bladder: multiple sclerosis, spinal cord
injury, cauda equina syndrome
Diabetes: osmotic dieresis, autonomic neuropathy
Parkinson’s disease: autonomic neuropathy
Investigations
Urinalysis and urine culture
Urine for cytology
PSA
RFT
Transrectal ultrasound guided prostatic needle biopsy
Urinary flow studies
Cystoscopy
References
Diagnosis and Management of Benign Prostatic Hyperplasia. American Family
Physician Volume 77, No. 10, May 15, 2008.
Lower Urinary Tract Symptoms in Men. http://www.patient.co.uk/
Dr. Chan Pang Fai
34) Lower urinary tract symptoms in women

 Lower urinary tract symptoms are common in women of all ages, but prevalence
increases with age.
Mostly filling symptoms (increased daytime frequency, nocturia, urgency, urinary
incontinence)
Pregnancy
Anxiety
Overactive bladder (idiopathic detrusor muscle overactivity)
Post menopausal urogenital atrophy
Bladder tumour or stone
Genital prolapse or pelvic mass
Neurological disease: e.g. multiple sclerosis
Drugs: diuretics
Mostly voiding symptoms (poor stream, hesitancy, intermittent stream, straining,

terminal dribble)
Age related detrusor muscle weakness
Obstruction: e.g. urethral stricture, urethral wall diverticulum, periurethral fibrosis,
pressure effects from pelvic masses or constipation
Urethritis and other genitourinary infections
Urethral syndrome: unknown cause; associated with urethral tenderness, dysuria,
frequency and incomplete voiding
Drugs:
Anticholinergics: Atropine and hyoscine compounds (isopropamide, mazindol,
phenothiazines, dicyclomine, propantheline, other belladonna alkaloids),
Tricyclic antidepressants, Anti-parkinson agents (amantadine, benzhexol,
benztropine, biperiden, orphenadrine, procyclidine)
Investigations
Pregnancy test
Urine for cytology
Dr. Chan Pang Fai
RFT
FBG
Genitourinary swabs for culture
Urodynamic studies (subtracted cystometry, uroflowmetry voiding, video
urodynamics)
Renal and/or post micturition ultrasound
Intravenous pyelogram
Cystoscopy
References
Lower Urinary Tract Symptoms in Women. http://www.patient.co.uk/
Dr. Chan Pang Fai
35) Lymphadenopathy
 Lymphadenopathy refers to nodes that are abnormal in either size, consistency
or number.
 Although the finding of lymphadenopathy sometimes raises fears about serious
illness, it is, in patients seen in primary care settings, usually a result of benign
infectious causes.
 Among primary care patients, the prevalence of malignancy has been estimated
to be as low as 1.1%. However, patients 40 years of age and older with
unexplained lymphadenopathy have about a 4% risk of cancer versus a 0.4% risk
in patients younger than age 40.
 Key risk factors for malignancy include older age, firm, fixed nodal character,
duration of greater than two weeks, and supraclavicular location.
 Lymph nodes are palpable as early as the neonatal period, and a majority of
healthy children have palpable cervical, inguinal, and axillary adenopathy.
 Localized adenopathy should prompt a search for an adjacent precipitating
lesion and an examination of other nodal areas. In general, lymph nodes greater
than 1 cm in diameter are considered to be abnormal.
 Supraclavicular nodes are the most worrisome for malignancy and should
always be investigated, even in children.
 Generalized adenopathy should always prompt further clinical investigation.
Common benign causes include adenoviral illness in children, mononucleosis,
and some pharmaceuticals.
 The presence or absence of tenderness does not reliably differentiate benign
from malignant nodes.
 A three- to four-week period of observation is prudent in patients with localized
nodes and a benign clinical picture.
 Specific testing is indicated if the history and examination suggest autoimmune
or more serious infectious diseases.
 While modern hematopathologic technologies have improved the diagnostic
yields of fine-needle aspiration, excisional biopsy remains the initial diagnostic
procedure of choice.
 If neoplasm is suspected, the work-up may involve laboratory testing or
radiologic evaluation, CT, MRI and USG, which has been particularly useful in
distinguishing benign from malignant nodes in patients with cancer of the head
and neck. However, definitive diagnosis is only obtained from biopsy.
Dr. Chan Pang Fai
Mnemonic acronym “MIAMI”: Malignancies, Infections, Autoimmune disorders,
Miscellaneous and unusual conditions, and Iatrogenic causes
Malignant
Lymphomas
Leukaemias
Skin neoplasms
Kaposi’s sarcoma
metastases
Infectious
URTI
Periodontal disease
Conjunctivitis
Lymphadenitis
Tinea
Insect bites
Brucellosis
Cat-scratch disease (Bartonella henselae infection)
Herpes simplex infection
HIV, primary infection
Lymphogranuloma venereum
Lyme disease
Mononucleosis
Pharyngitis
Rubella
Tuberculosis
Tularemia
Typhoid fever
Scrub typhus
Syphilis
Viral hepatitis
Bubonic plague
Coccidioidomycosis
Erysipeloid
Histoplasmosis
Dr. Chan Pang Fai
African trypanosomiasis (sleeping sickness)
American trypanosomiasis (Chaga’s disease)
Kala-azar (leishmaniasis)
Autoimmune
Lupus erythematosus
Dermatomyositis
Sjogren’s syndrome
Miscellaneous/unusual (SHAK)
Sarcoidosis, silicosis/berylliosis, storage disease (Gaucher’s disease,
Niemann-Pick disease, Fabry’s disease, Tangier disease)
Hyperthyroidism, Histiocytosis X, Hypertriglyceridaemia (severe)
Angiofollicular lymph node hyperplasia (Castleman’s disease),
angioimmunoblastic lymphadenopathy, amyloidosis
Kawasaki syndrome, Kikuchi’s lymphadenitis, Kimura’s disease
Sarcoidosis
Iatrogenic
Serum sickness
Medications: allopurinol, atenolol, captopril, carbamazepine, cephalosporins,
gold, hydralazine, penicillins, phenytoin, primidone, pyrimethamine, quinidine,
trimethoprim/sulfamethoxazole, sulindac
Recent immunization
Investigations
CBP, D/C: mononucleosis and other infectious diseases, leukaemias, lupus
erythematosus, rheumatoid arthritis, Sjogren’s syndrome
ESR: lupus erythematosus, rheumatoid arthritis, Sjogren’s syndrome
ANA, dsDNA: lupus erythematosus
RF: rheumatoid arthritis
LFT: viral hepatitis
CK: dermatomyositis
Serum complement levels: serum sickness
Blood culture: brucellosis, tularemia, typhoid fever
Serology: brucellosis, CMV, HIV, lymphogranuloma venereum, EBV (mononucleosis),
rubella, tularemia, viral hepatitis
Monospot test: mononucleosis
Widal test: typhoid
Dr. Chan Pang Fai
Reactive plasma regain: syphilis
CMV PCR: CMV
Serum ACE: sarcoidosis
Throat culture: pharyngitis
Sputum culture: tuberculosis
CXR: tuberculosis, sarcoidosis
Nodal biopsy: lymphomas, metastases, cat-scratch disease
Bone marrow biopsy: leukaemias, typhoid fever
Biopsy of skin lesion: skin neoplasms, Kaposi’s sarcoma
Lung/hilar biopsy: sarcoidosis
Muscle biopsy: dermatomyositis
Lip biopsy: Sjogren’s syndrome
Electromyography: dermatomyositis
Schirmer’s test: Sjogren’s syndrome
CT/MRI/USG
Dr. Chan Pang Fai
Peripheral Lymphadenopathy
References
Lymphadenopathy: Differential Diagnosis and Evaluation. American Family Physician,
October 15, 1998.
Lymphadenopathy and Malignancy. American Family Physician Volume 66, No. 11,
December 1, 2002.
Dr. Chan Pang Fai
36) Malaise/Tiredness/Fatigue
 Careful consideration must be given to the differentiation of physiological
tiredness, as a result of excessive physical activity, from psychological tiredness.
 Overwork is a common cause of fatigue and is often obvious to everyone but
the patient.
 The symptom of tiredness is likely to be ‘hidden’ behind the request for a tonic
or a physical check-up.
 No etiology can be identified in one third of cases of fatigue.
 Tiredness can be a symptom of a great variety of serious and uncommon
diseases, including malignant disease.
 The commonest cause of tiredness is psychological distress, including anxiety
states, depression and somatisation disorder. Research studies have reported
that over 50% of reported cases of fatigue have been of psychological causation.
 An important cause of daytime tiredness is a sleep disorder such as obstructive
sleep apnoea. It occurs in 2% of the general population in all age groups and in
about 10% of middle-aged men.
 Underlying disorders that need to be considered as possible causes of chronic
fatigue are endocrine and metabolic disorders, malignancy, chronic infection,
autoimmune disorders, primary psychiatric disorders, neuromuscular disorders,
anaemia, drugs and cardiovascular disorders.
 Chronic fatigue syndrome (CFS) is defined as a debilitating fatigue, persisting or
relapsing over 6 months, associated with a significant reduction in activity levels
of at least 50%, and for which no other cause can be found.
 The most probable diagnosis to consider are: tension, stress and anxiety,
depression, viral or post-viral infection, sleep-related disorders.
 Studies showed that investigating patients complaining of tiredness without
other significant history has a low rate of detection of significant disease.
 Investigations should be selected judiciously with the following tests that most
patients should have when the examination is completely normal: haemoglobin,
blood count and film, ESR/CRP, thyroid function tests, liver function tests, renal
function tests, serum calcium and magnesium, blood sugar, microscopy and
culture of urine.
 Women of childbearing age should receive a pregnancy test.
 Results of laboratory studies affect management in only 5% of patients, and if
initial results are normal, repeat testing is generally not indicated.
Dr. Chan Pang Fai
Psychogenic
Psychiatric disorders: anxiety states, depression, other primary disorders,
bereavement, somatisation disorder
Lifestyle factors: workaholic tendencies and ‘burnout’, lack of
exercise/sedentary lifestyle, mental stress and emotional demands, exposure to
irritants (e.g. carbon monoxide, ‘lead’ fumes), inappropriate diet, obesity, sleep
deprivation
Organic
Menopause syndrome
Pregnancy
Cardiovascular diseases: congestive cardiac failure, cardiac arrhythmia (e.g. sick
sinus syndrome), cardiomyopathy
Anaemia
Malignancy
HIV/AIDS
Subacute to chronic infection (e.g. urinary tract infection, hepatitis, malaria,
Lyme disease)
Endocrine: thyroid (hyper- and hypo-), adrenal (Cushing’s syndrome, Addison’s
disease), hyperparathyroidism, diabetes mellitus
Nutritional deficiency
Kidney failure
Liver disorders: chronic liver failure, chronic active hepatitis
Respiratory conditions (e.g. asthma, COPD)
Neurological and neuromuscular (e.g. multiple sclerosis, myasthenia gravis,
Parkinson’s disease, CVA, post head injury)
Metabolic (e.g. hypokalaemia, hypomagnesaemia)
Drug toxicity, addiction or side-effects (alcohol, analgesics, antibiotics,
anticonvulsants, antidepressants, antiemetics, antihistamines, antihypertensives,
anxiolytics, corticosteroids, ergot alkaloids, digoxin, hormones (e.g. oral
contraceptive), hypnotics, nicotine, NSAIDs, vitamins A and D (early toxic
symptoms)
Autoimmune disorders
Sleep-related disorders (e.g. OSA, narcolepsy)
Post-infectious fatigue syndrome (e.g. influenza, mononucleosis)
Haemochromatosis
Food intolerance
Dr. Chan Pang Fai
Coeliac disease
Unknown
Fibromyalgia
Chronic fatigue syndrome
Investigations
CBP, D/C, blood film
ESR/CRP
TFT
LFT/RFT
Ca, Mg
FBG
ANA
RF
Chronic infection screening: hepatitis A, B, C, D, E, CMV, EBV, Ross River virus, Lyme
disease, brucellosis, Q fever, tuberculosis, malaria, infective endocarditis,
toxoplasmosis
Plasma cortisol
Serum iron, ferritin, transferring saturation
HIV screening
Urine microscopy and culture
ECG and Holter
CXR
Spirometry
Muscle enzyme assay
Electromyography
Tissue markers for malignancy
Sleep study
References
Fatigue - A general diagnostic approach. Australian Family Physician Volume 32, No.
11, November 2003.
Pathology Testing in the Tired Patient. Australian Family Physician Volume 37, No. 11,
November 2008.
Fatigue: An Overview. American Family Physician Volume 78, No. 10, November 15,
2008.
Dr. Chan Pang Fai
37) Mastalgia
 Breast pain, or mastalgia, is a common problem accounting for at least 50% of
breast problems presenting in general practice.
 The commonest type is cyclical mastalgia. Premenstrual mastalgia is common.
 The typical age of cyclical mastalgia is 35 years while the typical age of
non-cyclical mastalgia is the early forties.
 An underlying malignancy should be excluded. Less than 10% of breast cancers
present with localized pain. Only about 1 in 200 women with mastalgia are
found to have breast cancer.
 Pain may also be a symptom of fibroadenoma.
 In the non-pregnant patient, generalized pain which may be cyclical or
non-cyclical is commonest. Cyclical mastalgia occurs in the later half of the
menstrual cycle, especially in the premenstrual days. The main underlying
disorder is benign mammary dysplasia, also referred to as fibroadenosis, chronic
mastitis, cystic hyperplasia or fibrocystic breast disease. Non-cyclical mastalgia is
also quite common and the cause is poorly understood. It may be associated
with duct ectasia and periductal mastitis.
 The three important serious disorders not to be missed are neoplasia, infection
and myocardial ischaemia.
 Important pitfalls include several musculoskeletal chest wall conditions
(costochondritis, pectoris muscle strains or spasm, and entrapment of the
lateral cutaneous branch of the third intercostals nerve, ankylosing spondylitis)
and referred pain from heart, oesophagus, lungs and gallbladder and thoracic
spine.
 Mastalgia may be the first symptom of pregnancy. Pregnancy should be
excluded before commencing drug treatment.
 Consider caffeine intake as a cause of benign diffuse mastalgia.
 In the absence of a mass, women 35 years of age and older should undergo
mammography unless a mammogram was obtained in the past 10 to 12 months.
The purpose of the study is to look for concurrent breast pathology in women
whose age places them at risk for breast cancer. When the physical examination
is normal, imaging studies are not indicated in women younger than 35 years of
age.
Pregnancy
Dr. Chan Pang Fai
Cyclical mastalgia (benign mammary dysplasia)
Chest wall pain e.g. costochondritis
Costochondritis
Pectoralis muscle spasm
Referred pain, esp. thoracic spine
Mechanical: bra problems, weight change, trauma
Infection: mastitis, abscess
Neoplasia
Myocardial ischaemia
Hyperprolactinaemia
Nerve entrapment
Mammary duct ectasia
Sclerosing adenosis
Ankylosing spondylitis
Drugs: oral contraceptives, HRT, theophylline; digoxin, cimetidine, spironolactone
and marijuana cause tender gynaecomastia
Investigations
Mammogram: should be considered in older women greater than 40 years
USG: can be complementary to mammography
Excision biopsy
References
The Evaluation of Common Breast Problems. American Family Physician, April 15,
2000.
Dr. Chan Pang Fai
38) Memory loss/Suspected dementia

 There are large individual differences in the amount of decline experienced by
individuals and in the patterns of decline across different abilities within and
individual.
 A practical indication of the amount of decline in normal aging can be gained
from the norms for commonly used cognitive tests.
 The significance of decline in cognitive abilities is partially determined by the
individual’s previous level of cognitive function.
 Memory complaints are common among older adults and are more prevalent
among the very old, women, and those with low levels of education.
 Self referrals for memory complaints are not a good indicator of cognitive
impairment and are more likely to be associated with depression in older adults.
 The diagnosis of mild cognitive impairment (MCI) has been developed for
research studies, particularly drug trials that focus on the detection and early
intervention of dementia.
 The criteria for MCI include:
 Subjective memory complaint
 Preserved general intellectual function demonstrated on performance of a
test of general cognitive abilities such as the mini-mental state examination
(MMSE)
 Impaired memory relative to age and education
 No impairment in performance of activities of daily living, and
 The absence of dementia
 Only 10-15% of patients diagnosed with MCI convert to dementia per year in
clinical populations and 5-10% in the community. A substantial proportion are
diagnosed as normal at follow up.
 There are no hard and fast rules to easily distinguish between normal aging and
dementia.
 Differentiating normal cognitive aging from MCI and early stage dementia
requires formal assessment by a neurologist, geriatrician or psychogeriatrician,
and ideally, a neuropsychologist.
 The incidence of dementia increases with age, affecting about 1 person in 10
over 65 years and 1 in 5 over 80 years.
 General practitioners should consider the four ‘Ds’ when considering differential
diagnosis in a patient with memory loss: dementia, delirium, drugs and
depression.
Dr. Chan Pang Fai
 Alzheimer’s disease and vascular dementia account for the majority of cases of
dementia.
 Screening instruments are available for use in general practice, but these only
yield a cut-off score that is associated with an established risk in population
based studies. The MMSE is a widely used instrument in which scores under 24
are generally taken to indicate cognitive impairment.
 Use of dementia screening instruments, depression screening instruments, and
tests for reversible causes of cognitive impairment and delirium are important
steps in the diagnostic process.
 Less than 10% of dementias are caused by treatable conditions.
 The American Academy of Neurology recommends two laboratory tests for the
initial evaluation of the patient with suspected dementia – thyroid function and
vitamin B12 level. The Second Canadian Consensus Conference on Dementia
(CCCD) recommends obtaining results for complete blood cell count,
thyroid-stimulating hormone level, serum electrolytes, serum calcium, and
serum glucose to exclude potential infections or metabolic causes for cognitive
impairment.
 Structural neuroimaging with noncontrast computed tomography or magnetic
resonance imaging also is recommended by the American Academy of
Neurology. Neuroimaging may diagnose vascular disease, normal pressure
hydrocephalus, tumors, abscess, or subdural haematoma. However, the yield in
identifying a potentially reversible cause of dementia is low.
 Other testing should be guided by the history and physical examination.
 Neuropsychologic testing can help determine the extent of cognitive
impairment, but it is not recommended on a routine basis. Neuropsychologic
testing may be most helpful in situations where screening tests are normal or
equivocal.
Normal cognitive impairment of ageing
Alzheimer’s disease (about 60%)
Dementia of frontal type (up to 10%)
Dementia with Lewy bodies (up to 10%)
Vascular dementia
Pick’s disease (Frontaltemporal dementia)
Mixed dementia
Parkinson’s disease
Dr. Chan Pang Fai
Delirium
Depression
Drug abuse
Alcohol-related dementia
Amnestic disorder
Various medical conditions
Anaemia
B12 deficiency
Hypothyroidism
Neurosyphilis
Encephalitis
Brain tumours
AIDS dementia
Cruetzfeldt-Jakob disease
Huntington’s disease
Trauma (subdural haematoma)
Cerebral Lyme disease
Mnemonic for dementia

D delirium, drugs
E emotional disorder = depression, endocrine = thyroid
M memory = benign forgetfulness
E elective = anxiety disorders/neuroses
N neurological: CVA, head trauma
T toxic: drugs/medication, metabolic disease
I intellect – low or retarded
A amnestic disorders – Korsakov’s
S Schizophrenia (chronic)
Investigations
CBP
ESR
LFT
RFT
Ca: hypercalcaemia
FBG
TFT: hypothyroidism
Dr. Chan Pang Fai
B12, folate
RPR: tertiary syphilis
HIV
Lyme disease titre
CT brain without contrast
CXR
ECG
Lipid
FBG
MSU for urinalysis and culture
Urine and serum toxicology screening: alcohol, salicylates, other
Heavy metal screen
EEG: if “slow-virus” or prion disease is suspected
MRI
PET
Lumbar puncture: suspected neurosyphilis, cerebral vasculitis, HIV infection,
slow-virus diseases, or cerebral Lyme disease
Apolipoprotein E: E4 status confers increased risk
Neuropsychological assessment
Dr. Chan Pang Fai
Initial Evaluation of Dementia
References
Normal Cognitive Changes in Aging. Australian Family Physician Volume 33, No. 10,
October 2004.
Diagnosis and Management of Dementia in General Practice. Australian Family
Physician Volume 33, No. 10, October 2004.
Early Diagnosis of Dementia. American Family Physician Volume 63, No. 4, February
15, 2001.
Initial Evaluation of the Patient with Suspected Dementia. American Family Physician
Volume 71, No. 9, May 1, 2005.
Dr. Chan Pang Fai
39) Menorrhagia/Irregular menses/Abnormal uterine bleeding

 Increased amount = menorrhagia
 Decreased amount = hypomenorrhoea
 Irregular and heavy periods = metromenorrhagia
 Irregular and light periods = oligomenorrhoea
 Vaginal bleeding before menarche is abnormal.
 Menstruation is abnormal if the cycle is less than 21 days, the duration of loss is
more than 7 days, or the volume of loss is such that menstrual pads of adequate
absorbency cannot cope with the flow or clots.
 Up to 50% of patients who present with perceived menorrhagia have a normal
blood loss when investigated.
 The possibility of pregnancy and its complications, such as ectopic pregnancy,
abortion (threatened, complete or incomplete), abruption placentae,
hydatidiform mole or chloriocarcinoma should be kept in mind.
 Menorrhagia is essentially caused by hormonal dysfunction, local pathology or
medical disorder. Two common organic causes of menorrhagia are fibroids and
adenomyosis. Other common organic causes are endometriosis, endometrial
polyps and pelvic inflammatory disease (PID).
 Various drugs can alter menstrual bleeding.
 For unknown reasons, cigarette smokers are five times more likely to have
abnormal menstrual function.
 Dysfunctional uterine bleeding (DUB) is common and occurs in 10-20% of
women at some stage. Peak incidence of ovulatory DUB is late thirties and
forties. Anovulatory DUB has two peaks: 12-16 years and 45-55 years.
 Dysfunctional uterine bleeding is the commonest cause of iron deficiency in the
developed world and of chronic illness in the developing world.
 Up to 40% with the initial diagnosis of DUB will have other pathology (e.g.
fibroids, endometrial polyps) if detailed endoscopic investigations are
undertaken.
 The incidence of malignant disease as a cause of bleeding increases with age,
being greatest after the age of 45, while endometrial cancer is predicted to be
less than 1 in 100000 in women under the age of 35.
 Abnormal pelvic examination findings, persistent symptoms, older patients and
other suspicions of disease indicate further investigation to confirm symptoms
of menorrhagia and exclude pelvic or systemic pathology.
 Menstrual irregularities are associated with both hypothyroidism (23.4% of
Dr. Chan Pang Fai
cases) and hyperthyroidism (21.5% of cases). Thyroid function tests may help
the physician determine the etiology.
 Endometrial cancer is rare in 15- to 18-years old females. Therefore, most
adolescents with dysfunctional uterine bleeding can be treated safely with
hormone therapy and observation, without diagnostic testing.
 Intermenstrual bleeding (IMB) should always be investigated. Order a pregnancy
test if appropriate. A Pap smear (should be done if one has not been taken
within the previous 3 months) in all age groups and endometrial sampling,
especially in the over 35 age group should be done to exclude cervical cancer
and intrauterine cancer.
 Endometrial evaluation (including imaging and tissue sampling) for subtle
genital tract pathology is recommended in patients who are at high risk for
endometrial cancer and in patients at low risk who continue bleeding
abnormally despite medical management.
 Postmenopausal women with abnormal uterine bleeding, including those who
have been receiving hormone therapy for more than 12 months, should be
offered dilatation and curettage for evaluation of the endometrium.
Vaginal bleeding before menarche
Malignancy
Trauma
Sexual abuse or assualt
Menorrhagia
Dysfunctional uterine bleeding (ovulatory)
Fibroids
Complications of hormone therapy
Adenomyosis
Disorders of pregnancy: ectopic pregnancy, abortion or miscarriage
Neoplasia: cervical cancer, endometrial cancer, leiomyosarcoma, leukaemia, benign
tumours – polyps, etc
Severe infections: PID
Endometrial hyperplasia
Genital tract trauma
IUCD
Endometriosis
Dr. Chan Pang Fai
Pelvic congestion syndrome
SLE
Thyroid disorders
Other endocrine disorders: Diabetes mellitus, adrenal hyperplasia, Cushing’s
disease
Bleeding disorder: thrombocytopenia, coagulopathies, leukaemia
Liver disorder
Renal disease
Drugs: anticoagulants, SSRIs, antipsychotics, corticosteroids, hormonal medications,
tamoxifen, herbal substances (ginseng, ginkgo, soy supplements), thyroxine
Irregular menses
Dysfunctional uterine bleeding (ovulatory)
Complications of hormone therapy
Disorders of pregnancy: ectopic pregnancy, abortion or miscarriage
Neoplasia: cervical cancer, endometrial cancer, leiomyosarcoma, leukaemia, benign
tumours – polyps, etc
Severe infections: PID
Endometrial hyperplasia
Genital tract trauma
IUCD
SLE
Thyroid disorders
Diabetes mellitus
Drugs
Intermenstrual bleeding and postcoital bleeding

Cervical ectropion/dysplasia
Cervical polyps
IUCD
OCP
Cervical cancer
Intrauterine cancer
Investigations
CBP: to exclude anaemia and thrombocytopenia
Iron studies
Dr. Chan Pang Fai
TFT
Clotting profile
LFT
RFT
FBG
ANA: SLE
Pregnancy test (urine PT and serum HCG)
Pap smear
Cervical and vaginal swabs
Trans-abdomen USG: for adolescents
Trans-vaginal USG: except in adolescents
Hysteroscopy and endometrial sampling
Hysteroscopy and D&C: gold standard for abnormal uterine bleeding
Saline-infusion sonohysterography
Endometrial biopsy
Laparoscopy: where endometriosis, PID or other pelvic pathology is suspected
Abnormal Uterine Bleeding in Women of Childbearing Age
Dr. Chan Pang Fai
Presumed Dysfunctional Uterine Bleeding in Women of Childbearing Age:
Evaluation Based on Risk Factors for Endometrial Cancer
Dr. Chan Pang Fai
Abnormal Uterine Bleeding in Postmenopausal Women
References
Dysfunctional Uterine Bleeding. Australian Family Physician Volume 33, No. 11,
November 2004.
Abnormal Uterine Bleeding. American Family Physician Volume 69, No. 8, April 15,
2008.
Dr. Chan Pang Fai
40) Monoarticular joint pain

 The commonest cause was osteoarthritis (OA). OA occurs in about 10% of adult
population and in 50% of those aged over 60.
 The usual cause of arthralgia is inflammation in the joint, that is arthritis, but a
function cause is encountered from time to time.
 Acute-onset monoarticular arthritis in children associated with fever is septic
until proven otherwise.
 Other common causes of monoarthritis are crystals, trauma, and infection.
 OA is very common with advancing age. Other musculoskeletal conditions that
become more prevalent with increasing age are: polymyalgia rheumatica,
Paget’s disease of bone, avascular necrosis, gout, pseudogout (pyrophosphate
arthropathy), malignancy (e.g. bronchogenic carcinoma).
 Joint pain may be referred from internal organs.
 Clinical acumen permits a judicious selection of specific tests rather than
ordering an expensive battery.
 Plan X-ray is invaluable, although in some conditions radiological changes may
be apparent only when the disease is well established. X-rays are also indicated
in patients with a history of trauma or patients who have had symptoms for
several weeks.
 Arthrography has limited value in the diagnosis of polyarthritis but is very useful
for specific joints such as the shoulder and the knee.
 Ultrasound examination for joints such as the shoulder and the hip can be very
useful.
 HLA-B27 should not be used for arthritis screening. It has a high sensitivity for
ankylosing spondylitis, but low specificity, and should rarely be ordered.
 The screening tests for diagnosis of the connective tissue disorders include
rheumatoid factor, antinuclear antibodies and dsDNA antibodies. But
indiscriminately ordering of such tests can result in confusion, because
false-positive results are common.
 Blood cultures should be obtained in patients with suspected septic arthritis.
Pharyngeal, urethral, cervical, and rectal swabs are necessary if gonococcal
infection is suspected.
Common causes
Osteoarthritis
Dr. Chan Pang Fai
Crystal deposition: gout, pyrophosphate (pseudogout), calcium oxalate, apatite, lipid
crystals
Trauma
Osteonecrosis
Infections: tuberculosis, brucellosis, pyogenic arthritis (gonococcus, staphylococcus,
non-group-A beta-hemolytic streptococci, gram-negative bacteria, and streptococcus
pneumonia; anaerobic and gram-negative in immunocompromised persons; fungi,
viruses), osteomyelitis
Avascular necrosis
Internal derangement of joint
Haemarthrosis
Less common and rare causes

Reactive arthritis
Juvenile rheumatoid arthritis
Spondyloarthropathies
Connective tissue disorders: SLE, systemic sclerosis, dermatomyositis
Neoplasia: carcinoma bronchus (hypertrophic osteoarthropathy), leukaemia,
lymphoma, neuroblastoma in children, metastatic diseases
Fibromyalgia syndrome
Dengue fever
Lyme disease
Ross River virus
Hyperthyroidism: causes acropathy and may present as pseudogout
Hypothyroidism: can present with an arthropathy or cause proximal muscle pain,
stiffness and weakness
Diabetes mellitus: can cause an arthropathy that can be painless or mild to
moderately painful
Other vasculitides: polyarteritis nodosa, hypersensitive vasculitis, Wegener’s
granulomatosis, Henoch-Schonlein purpura and Behcet’s syndrome
Serum sickness
Haemochromatosis
Sarcoidosis
Hyperparathyroidism
Dr. Chan Pang Fai
Familial Mediterranean fever
Amyloidosis
Pigemented villonodular synovitis
Still’s disease
Synovioma
Foreign-body synovitis
Intermittent hydrarthrosis
Investigations
CBP with differential WCC
ESR
CRP
Serum uric acid: up to 30% can be within normal limits with a true gouty attack
CaPO4
LFT
RFT
CK
RFT
RF: lacks both sensitivity and specificity: the test is positive in 5-10% of the general
population and negative in 20% of persons with rheumatoid arthritis, positive in 50%
in SLE, positive in 30% in scleroderma
Anti-CCP (anti-cyclic cirullinated peptide) antibodies: specific for RA (96%
specificity)
ANA: positive in 5-10% of the general population, positive in 95% in SLE, up to 90%
positive in scleroderma
dsDNA: specific for SLE but present in only 60%
ENA antibodies, especially Sm: highly specific for SLE
Antinucleolar and anticentromere antibodies: specific for scleroderma (positive in
90% with limited disease and 5% with diffuse)
HLA-B27: patients who are HLA-B27 positive and do not have a family history of
ankylosing spondylitis have only a 2% risk of developing this disorder
Various specific serological tests
HIV serology
Antistreptolysin O titre
Streptococcal anti-DNAse B
Streptococcal AHT
Blood and other culture
Dr. Chan Pang Fai
24hrs urinary uric acid
Urinalysis: blood, protein, sugar
Arthrocentesis of synovial fluid: analysis, culture
Radiology: X-ray, USG, CT, MRI (superior in detecting ischaemic necrosis, occult
fractures, and meniscal and ligamentous injuries)
Arthroscopy and biopsy
Bone scan: can detect infection in deep-sited joints
Diagnosing Acute Monoarthritis
References
Diagnosing Acute Monoarthritis in Adults: A Practical Approach for the Family
Physician. American Family Physician Volume 68, No. 1, July 1, 2003.
Dr. Chan Pang Fai
41) Multiple/polyarticular joints pain

 Polyarthritis implies the active inflammation of five or more joints.
 The commonest cause was osteoarthritis (OA).
 OA is very common with advancing age. Other musculoskeletal conditions that
become more prevalent with increasing age are: polymyalgia rheumatica,
Paget’s disease of bone, avascular necrosis, gout, pseudogout (pyrophosphate
arthropathy), malignancy (e.g. bronchogenic carcinoma).
 The population incidence of rheumatoid arthritis is 1-2%.
 Viral infections, crystal-induced arthritis, and serum sickness reactions are
common causes of acute, self-limited polyarthritis.
 Viral polyarthritis is more common than realized. It presents usually within 10
days of the infection, and is usually mild.
 Systemic diseases that may predispose to, or present with, an arthropathy
include the connective tissue disorder, diabetes mellitus, a bleeding disorder,
previous tuberculosis, the spondyloarthropathies such as psoriasis, SBE,
hepatitis B, rheumatic fever, the various vasculitis or arteritic syndromes (the
vasculitides) such as Wegener’s granulomatosis, HIV infection, carcinoma of the
lung, haemochromatosis, sarcoidosis, hyperparathyroidism and Paget’s disease.
 Infective causes that may be overlooked are dengue fever and Lyme disease.
 The usual cause of arthralgia is inflammation in the joint, that is arthritis, but a
function cause is encountered from time to time.
 Clinical acumen permits a judicious selection of specific tests rather than
ordering an expensive battery.
 Plan X-ray is invaluable, although in some conditions radiological changes may
be apparent only when the disease is well established.
 Arthrography has limited value in the diagnosis of polyarthritis but is very useful
for specific joints such as the shoulder and the knee.
 Ultrasound examination for joints such as the shoulder and the hip can be very
useful.
 HLA-B27 should not be used for arthritis screening. It has a high sensitivity for
ankylosing spondylitis, but low specificity, and should rarely be ordered.
 The screening tests for diagnosis of the connective tissue disorders include
rheumatoid factor (RF), antinuclear antibodies (ANA) and dsDNA antibodies. But
RF and ANA are non-specific. Results should be interpreted in the clinical
context and with caution.
 A complete count, urinalysis, and a metabolic panel may provide more useful
Dr. Chan Pang Fai
diagnostic clues.
Osteoarthritis
Viral arthritis
Spondyloarthropathies: ankylosing spondylitis, psoriatic arthritis, inflammatory
bowel disease, reactive arthritis (Reiter’s syndrome)
Connective tissue disorders: SLE, systemic sclerosis, dermatomyositis
Neoplasia: carcinoma bronchus (hypertrophic osteoarthropathy), leukaemia,
lymphoma, neuroblastoma in children, metastatic diseases
HIV arthropathy
Infections: tuberculosis, brucellosis, pyogenic arthritis (gonococcus, staphylococcus,
non-group-A beta-hemolytic streptococci, gram-negative bacteria, and streptococcus
pneumonia; anaerobic and gram-negative in immunocompromised persons; fungi,
viruses), osteomyelitis
Crystal deposition: gout, pyrophosphate (pseudogout)
Haemarthrosis
Dengue fever
Lyme disease
Ross River virus
Avascular necrosis
Hyperthyroidism: causes acropathy and may present as pseudogout
Hypothyroidism: can present with an arthropathy or cause proximal muscle pain,
stiffness and weakness
Diabetes mellitus: can cause an arthropathy that can be painless or mild to
moderately painful
Other vasculitides: polyarteritis nodosa, hypersensitive vasculitis, Wegener’s
granulomatosis, Henoch-Schonlein purpura and Behcet’s syndrome
Serum sickness
Haemochromatosis
Sarcoidosis
Hyperparathyroidism
Familial Mediterranean fever
Dr. Chan Pang Fai
Amyloidosis
Pigmented villonodular synovitis
Psychogenic: e.g. depression
Drugs (usually affects the hands and is symmetrical)
Drugs induced lupus syndrome: hydralazine, procainamide, quinidine,
antiepileptics (e.g. phenytoin), chlorpromazine, isoniazid, methyldopa, ACEIs
Others: statins, clotrimazole, amoxicillin, minocycline, mianserin, carbimazole,
progesterone only OCP, nitrofurantoin, antihypertensives, cimetidine,
famotidine
Arthritis in children
Infections
Rheumatic fever
Septic arthritis
Meningococcaemia
Osteomyelitis
Reactive arthritis (post-infectious)
Tuberculosis
Viral infection (e.g. rubella, mumps, varicella, CMV, erythema infectiosum,
influenza, HIV)
Inflammation-chronic arthritis
Juvenile chronic arthritis: Polyarticular (juvenile rheumatoid arthritis), Systemic
disease (Still’s syndrome), Juvenile ankylosing spondylitis
Psoriatic arthritis
Inflammatory bowel arthritis
Haematological disorders
Thalassaemia
Sickle-cell anaemia
Haemophilia
Neoplasms
Leukaemia
Lymphoma
Neuroblastoma
Orthopaedic conditions
Perthes’ disorder
Slipped upper femoral epiphyses
Chondromalacia
Dr. Chan Pang Fai
Others
Henoch-Schonlein syndrome
Kawasaki’s syndrome
Scurvy
Traumatic arthritis
Osteochondritis
Psychogenic rheumatism
Malignant tumour: bone, cartilage, synovium
Red flags for polyarthritis

Fever
Weight loss
Profuse rash
Lymphadenopathy
Cardiac murmur
Severe pain and disability
Malaise and fatigue
Vasculitic signs
Two or more systems involved
Investigations
CBP with differential WCC
ESR
CRP
Serum uric acid
CaPO4
LFT
RFT
CK
RF: lacks both sensitivity and specificity: the test is positive in 5-10% of the general
population and negative in 20% of persons with rheumatoid arthritis, positive in 50%
in SLE, positive in 30% in scleroderma
Anti-CCP (anti-cyclic cirullinated peptide) antibodies: specific for RA (96%
specificity)
ANA: positive in 5-10% of the general population, positive in 95% in SLE, up to 90%
positive in scleroderma
dsDNA: specific for SLE but present in only 60%
Dr. Chan Pang Fai
ENA antibodies, especially Sm: highly specific for SLE
Antinucleolar and anticentromere antibodies: specific for scleroderma (positive in
90% with limited disease and 5% with diffuse)
HLA-B27: patients who are HLA-B27 positive and do not have a family history of
ankylosing spondylitis have only a 2% risk of developing this disorder
Various specific serological tests
HIV serology
Antistreptolysin O titre
Streptococcal anti-DNAse B
Streptococcal AHT
Blood and other culture
24hrs urinary uric acid
Urinalysis: blood, protein, sugar
Arthrocentesis of synovial fluid: analysis, culture
Radiology: X-ray, USG, CT, MRI
Arthroscopy and biopsy
Bone scan
References
Diagnostic Approach to Polyarticular Joint Pain. American Family Physician Volume
68, No. 6, September 15, 2003.
Dr. Chan Pang Fai
42) Nausea and vomiting

 Nausea and vomiting have wide range of potential causes emanating from every
body system.
 The commonest cause of acute nausea and vomiting in most age group is
gastroenteritis or bacterial food poisoning.
 The most common causes of vomiting in children are infections – viral
(especially) and bacterial – including otitis media and urinary infection.
 Drug ingestion is a common cause of nausea and vomiting. Almost any
medication can cause nausea and vomiting.
 Vomiting is commonly associated with migraine. Children with cyclical vomiting
syndrome may have a genetic association with migraine.
 Surgical GIT causes are unlikely in the absence of abdominal pain.
 Pregnancy is the most common endocrinologic cause of nausea and must be
considered in any woman of childbearing age.
 Chronic nausea and vomiting are typically a pathologic response to any of a
variety of conditions.
 Consider anorexia nervosa and bulimia in adolescent females with a history of
vomiting immediately after meals, especially after binge eating.
 Early morning nausea and vomiting can be caused typically by alcohol,
pregnancy, kidney failure and raised intracranial pressure.
 Cyclical vomiting syndrome affects approximately 2% of the paediatric
population; the prevalence in adults is not known.
 Initial diagnostic testing should generally be limited to basic laboratory tests and
plan radiography. Further testing should be determined by clinical suspicion
based on a complete history and physical examination.
 In patients with unexplained symptoms, it is reasonable to perform a complete
blood count and erythrocyte sedimentation rate measurement in conjunction
with a complete metabolic profile.
 A pregnancy test should be performed in any woman of childbearing age.
 If a patient has abdominal pain, amylase should be performed.
 Supine and upright abdominal radiography should be performed if there is any
concern about a small bowel obstruction although false-negative results occur
in as many as 22% of patients with a partial obstruction.
 In patients with unexplained symptoms or with abnormal neurologic findings,
magnetic resonance imaging of the brain should be considered.
 Computerized tomography of the abdomen may be done to look for obstruction,
Dr. Chan Pang Fai
masses, pancreatic or hepatobiliary pathology.
Common
Acute gastroenteritis
Motion sickness
Drugs: alcohol, antibiotics especially erythromycin, antiarrhythmics, anticonvulsants,
antidepressants, antiparkinsonian drugs, bromocriptine, codeine, corticosteroids,
cytotoxic agents, digoxin, hormonal preparations, laxatives, levodopa, iron
preparations, metformin, nicotine and nicotine gum, NSAIDs, opioids, oral
contraceptives, salicylates, sulfasalazine, theophylline, vitamins (high dose)
Various infections
Feeding problems (neonates)
Viral infections/fever (children)
Otitis media (children)
UTI (children)
Gastritis/peptic ulcer
Alcohol intoxication
Pregnancy
Migraine
Gastrointestinal
Bowel obstruction
Oesophageal atresia (neonates)
Pyloric obstruction < 3 months
Intestinal malrotation or volvulus
Intussuception
Malignancy (e.g. oesophagus, stomach)
Gut motility disorders: achalasia
Paralytic ileus
Acute appendicitis
Acute pancreatitis
Acute cholecystitis
Function obstruction: diabetic gastroparesis, idiopathic gastroparesis
Strangulated hernia
Dr. Chan Pang Fai
Infection
Botulinum poisoning
Septicaemia
Meningitis/encephalitis
Infective endocarditis
Acute viral hepatitis
Pneumonia
Spontaneous bacterial peritonitis
Central nervous system

Closed head injury
Increased intracranial pressure: CVA, hydrocephalus, mass lesion, pseudotumor
cerebri
Labyrinthine disorders: Meniere’s syndrome, layrinthitis
Seizure disorders
Metabolic and endocrine

Addison disease (Addison crisis)
Diabetic ketoacidosis
Paraneoplastic syndromes
Parathyroid disorders
Thyroid disorders: hyper-/hypothyroidism
Uremia
Hypercalcaemia
Phaeochromocytoma
Organic acidurias
Fatty acid oxidation defects
Mitochondrial disorders
Urea cycle defects
Aminoaciduria
Miscellaneous
Acute glaucoma
Acute myocardial infarction
Organic failure: liver, kidney, heart, respiratory
Poisoning: chemicals such as arsenic, organophosphates/pesticides, ricin
Substance abuse
Dr. Chan Pang Fai
Nephrolithiasis
Pain
Radiation therapy
Psychiatric disorders: anorexia nervosa and bulimia nervosa, conversion disorder,
depression, anxiety
Cyclical vomiting syndrome
Malignancy: lung, endocrine, gastrointestinal
Investigations
CBP, D/C: leukocytosis in an inflammatory process, microcytic anaemia from a
mucosal process
ESR: inflammatory process
LFT: for alcoholic, patients with upper abdominal pain or jaundice
RFT and venous astrup: consequences of nausea and vomiting (e.g., acidosis,
alkalosis, azotemia, hypokalaemia)
Ca: hypercalcaemia
Amylase: pancreatitis
TFT: hyperthyroidism
Fasting cortisol +/- synacthen test: Addison disease
PT: for any female of childbearing age
Urinalysis
Urine culture
Microscopy and culture of stools
Drug toxicity studies
Radiology of GIT
Plain X-ray abdomen (supine and upright): mechanical obstruction
Barium meal
Small bowel follow-through
USG
CT: obstruction, optimal technique to localize other abdominal pathology
Gastro emptying scintigraphy: gastroparesis
MRI brain: intracranial mass or lesion
Oesophageal motility studies
OGD: mucosal lesions, proximal mechanical obstruction
ECG
Dr. Chan Pang Fai
Evaluation of Nausea and Vomiting
References
Evaluation of Nausea and Vomiting. American Family Physician Volume 76, No. 1, July
1, 2007.
Nausea and Vomiting in Adults – A Diagnostic Approach. Australian Family Physician
Volume 36, No. 9, September 2007.
Functional Nausea and Vomiting. Australian Family Physician Volume 36, No. 9,
September 2007.
Cyclic Nausea and Vomiting in Childhood. Australian Family Physician Volume 36, No.
9, September 2007.
Dr. Chan Pang Fai
43) Neck pain

 The main cause of neck pain is a disorder of the cervical spine, which usually
manifests as neck pain but can refer pain to the head, shoulders and chest. Such
pain usually originates from the facet joints but can arise from other
musculoskeletal structures, such as the intervertebral discs and the muscles or
ligaments.
 The commonest cause of neck pain is idiopathic dysfunction of the facet joints
without a history of injury.
 In a UK study, radiological cervical disc degeneration was present in 40% of
males and 28% of females between 55 and 64 years.
 Strains, sprains and fractures of the facet joints, especially after a ‘whiplash’
injury are difficult to detect and are often overlooked as a cause of persistent
neck pain.
 Spondylosis, known also as degenerative osteoarthrosis and osteoarthritis, is
also a common cause, especially in the elderly patients.
 Intervertebral disc disruption is also a relatively common phenomenon in the
cervical spine, especially at the lower levels C5-6 and C6-7.
 Radioculpathy can be caused by a soft disc protrusion, a hard calcified lump and
osteophytes.
 Conditions causing neck pain and stiffness may be a sign of meningitis or of
cerebral haemorrhage, particularly subarachnoid haemorrhage, or of a cerebral
tumour or retropharyngeal abscess.
 Angina and myocardial infarction should be considered in anterior neck pain.
Other visceral disorders can refer pain to the neck.
 Arterial dissection of the internal carotid artery or vertebral artery should be
kept in mind in patients presenting with acute neck pain, especially without
musculoskeletal symptoms or signs.
 Tumours are relatively rare in the cervical spine but metastases do occur and
should be kept in mind. Metastases to the spine occurs in 5-10% of patients with
systemic cancer. The cervical spine accounts for some 15% of spinal metastases.
 Rheumatoid arthritis is the prime severe inflammatory arthropathy that involves
the neck but the neck can be affected by the seronegative
spondyloarthropathies, particularly ankylosing spondylitis, psoriasis and the
inflammatory bowel disorders.
 While polymyalgia rheumatica affects mainly the shoulder girdle, pain in the
lower neck, which is part of the symptom complex, is often overlooked. Diffuse
Dr. Chan Pang Fai
neck pain in myofascial soft tissue with tender trigger areas is part of the
uncommon but refractory fibro-myalgia syndrome.
 In children and adolescents neck pain, often with stiffness, may be a
manifestation of infection or inflammation of cervical lymph nodes, usually
secondary to an infected throat.
 Acute neck pain is most commonly idiopathic or due to a whiplash accident.
People wake up with severe neck pain is usually caused by an unusual twist on
the flexed neck for a long period during sleep.
 X-rays are not indicated for the investigation of acute neck pain in the absence
of ‘red flags’ and a history of trauma. But X-ray is required for whiplash injury. All
acutely painful conditions of the cervical spine following trauma should be
investigated with a careful neurological examination of the limbs, sphincter tone
and reflexes. Plain film radiology is mandatory.
 In conscious patients, flexion and extension lateral cervical spinal plain films are
useful for diagnosing instability of spinal segments with or without associated
spinal fractures.
 It is inappropriate to perform sophisticated investigations such as CT scans on
most patients. Scanning should be reserved where surgery is contemplated and
serious disease is suspected but not confirmed by plain X-ray.
Musculoskeletal
Joint dysfunction: apophyseal, intervertebral disc
Muscular/ligamentous strains or sprains
Trauma: whiplash, fracture, other disorders
Disc prolapse
Inflammation
Osteoarthritis
Ankylosing spondyliitis
Psoriasis
Inflammatory bowel disorders
Reiter’s syndrome/reactive arthritis
Polymyalgia rheumatic
Thyroiditis
Cervical lymphadenitis
Dr. Chan Pang Fai
Infective
Spinal: osteomyelitis, tuberculosis, herpes zoster
Extraspinal: cervical adenitis, poliomyelitis, tetanus
Extracervical: meningitis, febrile states (meningism, malaria)
Degenerative
Spondylosis
Neoplasia
Benign, malignant, metastases
Referred visceral
Heart: IHD, pericarditis, arterial dissection
Oesophagus
Carcinoma lung (Pancoast tumour)
Referred cranial
Haemorrhage (e.g. subarachnoid)
Tumour
Abscess
Psychogenic
Outlet compression syndrome (e.g. cervical rib)
Investigations
CBP, D/C
ESR
RF
HLA-B27
Plain X-ray
CT
CT myelogram: most accurate for myelopathy and if cervical disc surgery
contemplated
Radionuclide bone scan: for suspected metastatic disease
MRI: for cervical radiculopathy, myelopathy, suspected spinal infection and tumour
Electromyography: may help delineate lesions causing radioculopathy requiring
Dr. Chan Pang Fai
surgery.
References
Neck Pain. http://www.ecureme.com.
Neck Pain in Adults. http://www.patient.co.uk.
Dr. Chan Pang Fai
44) Nipple discharge

 Fluid can be obtained from the nipples of 50-70% of asymptomatic women
when massage with breast pumps. This discharge of fluid from a normal breast
is referred to as “physiological discharge”.
 Abnormal discharge (i.e. discharge that is spontaneous, single duct, and clear or
blood-stained) needs investigation.
Physiological discharge: unilateral or bilateral yellow, milky or green discharge
Duct ectasia: bilateral yellow, green, or brown discharge from multiple ducts
Duct papilloma: clear or blood-stained discharge may rarely be associated with duct
papilloma
Nipple eczema: weeping, crusty nipple discharge
Breast cancer: only 3% of women with breast cancer have nipple discharge, more
likely to be in situ than invasive
Paget disease: blood-stained discharge with ulceration and erosion of the nipple
Hyperprolactinaemia: bilateral, pituitary and thyroid disease and drug causes (oral
contraceptives, hormone therapy, antiemetics, antipsychotics, cocaine, and
stimulants)
Investigations
Prolactin: hyperprolactinaemia
Mammogram: abnormal discharge
Breast USG: abnormal discharge
Cytology of nipple fluid: limited accuracy and should only be performed selectively
in women with spontaneous blood-stained single duct discharge
Ductography/galactography: may be helpful
References
Management of Benign Breast Conditions. Australian Family Physician Volume 34,
Number 5, October 2005.
Dr. Chan Pang Fai
45) Palpitation
 Palpitations not related to emotion, fever or exercise suggest an arrhythmia.
 Perhaps the commonest arrhythmia causing a patient to visit the family doctor
is the symptomatic premature ventricular beat/complex (ventricular ectopic).
 The commonest cause of an apparent pause on the ECG is a blocked premature
atrial beat/complex (atrial ectopic).
 The common causes are sinus tachycardia and premature complexes.
 Paroxysmal supraventricular tachycardia (SVT) and atrial fibrillation (AF) are also
quite common arrhythmias.
 PSVT is rarely caused by organic heart disease in young patients.
 Consider myocardial ischaemia as a cause of the arrhythmia.
 Sinister life-threatening arrhythmias are: ventricular tachycardia, atypical
ventricular tachycardia (torsade de pointes), sick sinus syndrome (SSS),
complete heart block.
 Most patients with arrhythmias do not complain of palpitations.
 Nonarrhythmia cardiac problems, such as mitral valve prolapsed, pericarditis,
and congestive heart failure can cause palpitations.
 Anaemia can cause palpitation due to a haemodynamic effect.
 The older the patient the more likely the onset of palpitation due to cardiac
disease such as myocardial infarction/ischaemia, hypertension, arrhythmias and
drugs, especially digoxin.
 Occasional atrial and ventricular arrhythmias, especially premature complexes,
occur in 40% of old people.
 Atrial fibrillation occurs in 5-10% of patients over 65 years of age, 30% of whom
have no clinical evidence of cardiovascular disease.
 Palpitations should be considered as potentially more serious if they are
associated with dizziness, near-syncope, or syncope.
 In the elderly, thyrotoxicosis may present as sinus tachycardia or atrial
fibrillation with only minimal signs – the so-called ‘masked thyrotoxicosis’
 Consider drugs as a cause, including prescribed drugs and non-prescribed such
as alcohol, caffeine and cigarettes.
 Evidence of anxiety and depression should be sought in patients presenting with
palpitations without clinical evidence of cardiovascular disease.
 No cause for palpitations can be found in up to 16% of patients.
 A 12-lead ECG evaluation is appropriate in all patients who complain of
palpitations.
Dr. Chan Pang Fai
 Many ECG findings warrant further cardiac investigation. These findings include
evidence of previous myocardial infarction, left or right ventricular hypertrophy,
atrial enlargement, atrial ventricular block, short PR interval and delta waves or
prolonged QT interval.
 Occasionally, the finding of an isolated premature ventricular contraction or
premature atrial contraction warrants further monitoring or exercise testing.
 A normal ECG in sinus rhythm does not exclude an accessory pathway.
 In patients of low risk for coronary heart disease who have no
palpitation-associated symptoms such as dizziness, and who have negative
physical examination and ECG findings, palpitations may need no further
evaluation unless the episodes persist or the patient remains anxious for an
explanation.
 Ambulatory electrocardiography (ECG) monitoring usually is indicated if the
etiology of palpitations cannot be determined from the patient’s history,
physical examination, and resting ECG.
 When palpitations occur unpredictably or do not occur daily, an initial two-week
course of continuous closed-loop event recording is indicated.
 Holter monitoring for 24 to 48 hours may be appropriate in patients with daily
palpitations.
 Blood tests may be appropriate in the following conditions: complete blood cell
count for suspected anaemia or infection, electrolytes for arrhythmia from
suspected electrolyte disturbance, and thyroid-stimulating hormone for
suspected hyperthyroidism.
 ECG exercise testing is appropriate in patients who have palpitations with
physical exertion and patients with suspected coronary artery disease or
myocardial ischaemia.
 Electrophysiological studies are the gold standard investigation for tachycardia
but are rarely needed for diagnosing most arrhythmias.
 Findings from the physical examination or ECG may suggest the need for
echocardiography to evaluate structural abnormalities.
Anxiety
Premature beats (entopic)
Sinus tachycardia
Drugs: alcohol, aminophylline, anti-arrhythmic drugs, antidepressants (tricyclics,
MAOIs), caffeine, class 1A and 1C drugs, cocaine, digitalis, diuretics (cause
Dr. Chan Pang Fai
hypokalaemia and hypomagnesaemia), glyceryl trinitrate, sympathomimetics (in
decongestants, salbutamol, terbutaline), theophylline, thyroxine
Myocardial infarction/angina
Arrhythmias: ventricular tachycardia, bradycardia, sick sinus syndrome, torsade de
pointes
Thyrotoxicosis
WPW syndrome
Long QT syndrome
Electrolyte disturbances: hypokalaemia, hypomagnesaemia, hypoglycaemia
Fever
Infection
Pregnancy
Menopause
Anaemia
Mitral valve disease
Aortic incompetence
Hypoxia/hypercapnia
Tick bites (toxin in dermatoses T1-5)
Phaeochromocytoma
Depression
Panic disorder
Investigations
CBP
TFT
RFT
Magnesium
Serum digoxin: digitalis toxicity
Virus antibodies: myocarditis
CXR
ECG
Ambulatory 24-hour ECG
Echocardiography: valvular heart disease and assess left ventricular function
Electrophysiology studies
Exercise stress test: underlying CAD
Dr. Chan Pang Fai
Evaluating a Patient with Palpitations
References
Diagnostic Approach to Palpitations. American Family Physician Volume 71, Number
4, February 15, 2005.
Dr. Chan Pang Fai
46) Penile discharge

 Urethritis is the most common cause of penile discharge.
 Urethritis is an inflammation condition that can be infectious or posttraumatic
in nature.
 Infectious cause of urethritis are typically sexually transmitted and categorized
as either gonococcal urethritis (GU) or non-gonococcal urethritis (NGU) (i.e. due
to infections with Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma
hominis, Mycoplasma genitalium, or Trichomonas vaginalis).
 Patients with GU have a shorter incubation period compared to those with NGU,
and the onset of dysuria and purulent discharge is abrupt.
 Rare infectious causes of urethritis include lymphogranuloma venereum, herpes
genitalis, syphilis, mycobacteria, and typical bacteria associated with cystitis in
the presence of urethral stricture.
 Post-traumatic urethritis can occur in 2-20% of patients practicing intermittent
catheterization and following instrumentation or foreign body insertion.
 Urethritis may be associated with other infectious syndromes such as
epididymitis, orchitis, prostatitis, proctitis, Reiter syndrome, iritis, pneumonia,
otitis media, or urinary tract infection.
 All patients with urethritis should be tested for Neisseria gonorrhea and
Chlamydia trachomatis.
Non-specific urethritis
Sexually transmitted disease
Gonorrhea
Chlamydia
Trichomonas
Non-gonococcal urethritis
Foreign body in urethra
Prostatitis
Balanitis
Mechanical urethritis: trauma or damage to the urethra from physical injury (e.g.
cycling, horse riding, excessive masturbation, etc.)
Post-traumatic urethritis
Chemical urethritis caused by spermicides
Reiter’s syndrome
Dr. Chan Pang Fai
Cancer of penis
Dried semen mistaken for discharge
Investigations
Endourethral culture for N gonorrhea and C trachomatis
Urinalysis and urine for culture: not useful except for helping exclude UTI
Polymerase chain reaction (PCR) Chlamydia urine test on first catch urine specimen
Ligase chain reaction (LCR) Chlamydia urine test: 90-95% sensitive, 100% specific
STD screening: Rapid Plasma Reagin (RPR) test for syphilis, HIV serology
ESR: elevated in Reiter syndrome
HLA-B27 testing: of limited value in diagnosis of Reiter syndrome
Retrograde urethrogram: trauma and possible foreign body insertion
Cystoscopy: foreign body
References
Urethritis. http://emedicine.medscape.com.
Penis discharge. http://www.wrongdiagnosis.com.
Dr. Chan Pang Fai
47) Pruritus
 The broad differential diagnoses of pruritus are: skin disease, systemic disease,
psychological and emotional disorders.
 Localized itching is generally caused by common skin conditions such as atopic
dermatitis.
 Pruritus can be a manifestation of systemic disease.
 Patients, particularly elderly adults, with severe pruritus that does not respond
to conservative therapy should be evaluated for an underlying systemic disease.
 Pruritus can be an important dermatologic clue to the presence of significant
underlying disease in 10 to 50% of older adults.
 Pruritus can accompany pregnancy, especially towards the end of the third
trimester (beware of cholestasis), and disappear after childbirth.
 The prevalence of itching in Hodgkin’s lymphoma is about 30%.
 Patients with human immunodeficiency virus (HIV) infection commonly have
itching, which is most often considered secondary to comorbid dermatologic
conditions such as xerosis, seborrhoeic dermatitis, candidiasis, psoriasis, scabies,
or eosinophilic folliculitis.
 Uremia causes severe paroxysms of pruritus in 25% of patients with chronic
renal failure and 86% of patients who are receiving haemodialysis.
 Pruritus can be the presenting symptoms of primary biliary cirrhosis and may
precede other symptoms by 1-2 years.
 Pruritus can occur in both hyperthyroidism and hypothyroidism, especially in
hypothyroidism where it is associated with the dry skin.
 If pruritus does not respond to two weeks of symptomatic therapy, or if an
underlying systemic cause is suspected, a limited laboratory evaluation is
indicated.
Primary skin disorders
Atopic dermatitis
Urticaria
Dermatitis herpetiformis
Psoriasis
Grover’s disease (transient acantholytic dermatosis)
Scabies
Pediculosis
Dr. Chan Pang Fai
Asteatosis (dry skin)
Lichen planus
Chickenpox
Contact dermatitis
Insect bites
Senile pruritus
Fungal infection
Bullous pemphigoid
Mycosis fungoides (Cutaneous T-cell lymphoma)
Pregnancy
Chronic kidney failure
Hepatic disorder
Cholestatic jaundice: e.g. carcinoma of head of pancreas, primary biliary
cirrhosis, drugs: chlorpromazine, antibiotics (erythromycin, augmentin),
phenothiazines, anabolic steroids, contraceptive pills
Hepatic failure
Chronic pancreatitis
Malignancy
Lymphoma: Hodgkin’s lymphoma
Leukaemia, esp. chronic lymphatic leukaemia
Multiple myeloma
Disseminated carcinoma
Malignant carcinoid
Polycythaemia rubra vera
Iron-deficiency anaemia
Pernicious anaemia
Macroglubulinaemia
Endocrine disorders
Diabetes mellitus
Hypothyroidism
Hyperthyroidism
Carcinoid syndrome
Hyperparathyroidism
Neurological
Postcerebral infarction
Multiple sclerosis
Dr. Chan Pang Fai
Malabsorption syndrome
Tropical infection/infestinal parasites: filariasis, hookworm, schistosomiasis,
onchocerciasis, trichinosis
Parvovirus B19 infection
Peripheral neuropathy: brachioradial pruritus, herpes zoster, nostalgia paraesthetica
Scleroderma
Rapid weight loss in eating disorders
Drugs: alkaloids, opiates, cocaine, quinidine, chloroquine, CNS stimulants
Polyarteritis nodosa
Irritants: fiberglass, topical antibiotics
HIV infection
Psychological and emotional causes: anxiety/depression, psychosis, parasitophobia
Investigations
Urinalysis
Pregnancy test
CBP
ESR
RFT
LFT
TFT
FBG
HIV serology
Stool for ova and cysts
CXR
Lymph node biopsy
Immunological tests for primary biliary cirrhosis
Skin scraping for fungal culture and scabies
Skin biopsy
Dr. Chan Pang Fai
Evaluation of Pruritus
References
Pruritus. American Family Physician Volume 68, Number 6, September 15, 2003.
Itch: A Symptom of Occult Disease. Australia Family Physician Volume33, Number 7,
July 2004.
Dr. Chan Pang Fai
48) Pyrexia of unknown origin/Fever of undetermined origin

 Fevers due to infections have an upper limit of 40.5-41.1°C (105-106°F)
 Hyperthermia (temperature above 41.1°C) and hyperpyrexia appear to have no
upper limit. Hyperthermia may be observed particularly in the tropics, in
malaria and heatstroke. It can occur with CNS tumours, infections or
haemorrhages because of its effect on the hypothalamus.
 Infection remains the most important cause of acute fever.
 General causes of fever include infections, malignant disease, mechanical
trauma (e.g. crush injury), vascular accidents (e.g. infarction, cerebral
haemorrhage), immunogenic disorders (e.g. drug reactions, SLE), acute
metabolic disorders (e.g. gout), and haemopoietic disorders (e.g. acute
haemolytic anaemia).
 Drugs can cause fever, presumably because of hypersensitivity. Drug fever
should abate by 48 hours after discontinuation of the drug.
 Overseas travelers or visitors may have special, even exotic infections and
require special evaluation.
 Fever of less than 3 days duration is often due to a self-limiting viral infection of
the respiratory tract. It is important, however, to be vigilant for other infections,
so evidence of infectious disease, urinary tract infection, pneumonia or other
infection should be sought.
 If fever persists beyond 4-5 days a less common infection should be suspected
since most common viral infections will have resolved by about 4 days.
 Fever of undetermined origin (FUO), has the following criteria: illness for at least
3 weeks, fevers > 38.3°C (100.9°F), undiagnosed after 1 week of intensive study.
 Most cases of FUO represent unusual manifestations of common diseases and
not rare or exotic diseases.
 The longer the duration of fever, the less likely the diagnosis is to be infectious –
fevers that last greater than 6 months are rarely infectious (6%). One study
showed that 9% are factitious.
 Patients with FUO in definite need of further investigation are: babies < 3
months of age, children with fever > 40°C, adults > 50years, diabetics, the
immunocompromised, travelers.
 Common causes of prolonged fever in children differ from those in adults. Most
cases are not due to unusual or esoteric disorders, the majority representing
atypical manifestation of common diseases.
 A thorough history, physical examination, and standard laboratory testing
Dr. Chan Pang Fai
remain the basis of the initial evaluation of the patient with FUO.
 Even with a thorough history and a complete physical examination, one in five
acutely ill, non-toxic-appearing children have an unidentifiable source of fever.
 Newer diagnostic modalities, including updated serology, viral cultures,
computed tomography, and magnetic resonance imaging, have important roles
in the assessment of these patients.
 A cost-effective individualized approach is essential to the evaluation of these
patients, and without a thoughtful and focused investigation, inappropriate tests
might be performed.
 The preliminary investigation should include a complete blood count, liver
function test, erythrocyte sedimentation rate, urinalysis, and basic cultures. The
decision to obtain further diagnostic studies should be based on abnormalities
found in the initial laboratory work-up and not represent a haphazard use of
costly or invasive modalities.
 Abdominal sonography, pelvic sonography, or CT scanning should be performed
early in the diagnostic process to rule out such common causes of FUO as
intra-abdominal abscess or malignancy.
 Any infant younger than 29 days and any child that appears toxic should
undergo a complete sepsis work-up. However, nontoxic-appearing children one
to 36 months of age, who have a fever with no apparent source and who have
received the appropriate vaccinations, could undergo screening laboratory
analysis and be sent home with close follow-up.
Infection (up to 40%)
Bacteria
Pyogenic abscess (e.g. liver, pelvic, dental)
Urinary infection
Biliary infection (e.g. cholangitis)
Chronic septicaemia
Lyme disease
Tuberculosis
Osteomyelitis
Typhoid/paratyphoid fever
Prostatitis
Viral, rickettsial, Chlamydia
Dr. Chan Pang Fai
Epstein-Barr mononucleosis
Cytomegalovirus
HIV virus infection (AIDS, ARC)
Q fever
Psittacosis
Parasitic
Malaria
Toxoplasmosis
Amoebiasis
Malignancy (up to 30%)
Reticuloendothelial
Leukaemia
Lymphomas
Myelodysplastic syndrome
Solid (localized) tumours
Kidney
Liver
Pancreas
Stomach
Lung
Sarcoma
Disseminated
Immunogenic (up to 20%)
Drugs: allopurinol, antihistamines, barbiturates, captopril, cephalosporins, cimetidine,
clofibrate, erythromycin, heparin, hydralazine, hydrochlorothiazide, isoniazid,
meperidine, methyldopa, nifedipine, nitrofurantoin, penicillins, phenolphthalein
(including laxatives), phenytoin, procainamide, procainamide, quinidine, salicylates,
sulphonamides
Connective tissue diseases/vaculitides
Adult Still’s disease
Rheumatic fever
SLE
Polyarteritis nodosa/Wegener’s granulomatosis
Giant cell arteritis/polymyalgia rheumatic
Reiter’s syndrome
Hepatitis (alcoholic, granulomatous, or lupoid)
Dr. Chan Pang Fai
Deep venous thrombosis
Sarcoidosis
Inflammatory bowel disease e.g. Crohn’s
Factitious (1-5%)
Remain unknown (5-9%)
Common causes of FUO in children

Infectious causes (40%)
Viral syndrome
Pneumonia
Pharyngitis
Sinusitis
Meningitis
Collagen-vascular disorders (15%)
Rheumatic arthritis
Systemic lupus erythematosus
Rheumatic fever
Henoch-Schonlein syndrome
Neoplastic disorders (7%)
Leukaemia
Reticulum cell sarcoma
lymphoma
Investigations
CBP, D/C, blood film
ESR
CRP
CXR: should be obtained in all patients to screen for possible infection, collagen
vascular disease, or malignancy
X-ray sinuses
RFT
LFT
blood cultures
Stool for microscopy and culture
Sputum culture
Dr. Chan Pang Fai
Specific test for typhoid, EBV, Q fever, brucellosis, psittacosis, cytomegalovirus,
toxoplasmosis, syphilis and others
HIV screening
Tests for rheumatic fever
Tuberculin test
Tests for connective tissue disorders (e.g. DNA antibodies, CRP)
Upper GIT series with small bowel follow-through
CT and USG for primary and secondary neoplasia: gall bladder functioning, occult
abscesses
MRI: lesions of the nervous system, for clarifying conditions found through the use of
other techniques or when the diagnosis remains obscure
Echocardiography: suspected endocarditis
Isotope scanning for specific causes of inflammatory conditions and neoplastic
lesions that often are underdiagnosed by CT scans
Aspiration or needle biopsy
Laparoscopy for suspected pelvic infection
Endoscopy: helpful in diagnosis of disorders such as inflammatory bowel disease and
sarcoidosis
Positron emission tomography (PET): very high negative predictive value in ruling
out inflammatory causes of fever
Lumbar puncture
Tissue biopsies (e.g. lymph nodes, skin, liver, bone marrow) as indicated
Diagnosis of Fever of Unknown Origin
Dr. Chan Pang Fai
Treatment of Child with Fever of Unidentifiable Source
References
Approach to the Adult Patient with Fever of Unknown Origin. American Family
Physician Volume 68, Number 11, December 1, 2003.
Evaluating Fever of Unidentifiable Source in Young Children. American Family
Physician Volume 75, Number 12, June 15, 2007.
Dr. Chan Pang Fai
49) Raynaud’s phenomenon

 Raynaud phenomenon should be distinguished from Raynaud disease which is
the occurrence of the vasospasm alone, with no association with another
illness.
 The incidence of primary Raynaud is 3-4% in persons who are nonsmokers.
 The frequency of secondary Raynaud depends on the underlying disorder.
 Vasospastic symptoms may predate systemic disease by as much as 20 years. In
some studies, 46-81% of patients have secondary Raynaud.
 The benign form is the commonest, but may indicate an evolving connective
tissue disorder.
 It is highly significant if it extends to the metacarpophalangeal joints.
 The most common association is with progressive systemic sclerosis and mixed
connective-tissue disease.
 Raynaud phenomenon has also been described with such diverse diseases as
systemic lupus erythematosus and other disorders not classified as autoimmune,
including frostbite, vibration injury, polyvinyl chloride exposure, and
cryoglobulinemia
 Bone pain may suggest a paraneoplastic syndrome associated with a
hyperviscosity syndrome.
 Persistent cyanosis or necrotic distal tissue suggests an underlying disorder or
permanent ischaemia.
Primary
Raynaud’s disease (idiopathic)
Secondary
Occupational trauma (vibrating machinery)
Connective tissue/autoimmune disorders
Systemic sclerosis, CREST syndrome
Polyarteritis nodosa
Dermatomyositis and polymyositis
Systemic lupus erythematosus
Sjogren syndrome
Vasculitis
Dr. Chan Pang Fai
Mixed connective-tissue disease
Antiphospholipid antibody syndrome
Pregnancy
Arterial disease
Buerger’s disease (thromboangiitis obliterans)
Polycythaemia
Cold agglutinin disease
Cryofibrinogenemia
Paroxysmal nocturnal haemoglobinuria
Infections
Hepatitis B and C (especially associated with mixed or type 3 cryoglobulinemia)
Mycoplasma infections (with cold agglutinins)
Neoplastic syndromes
Lymphoma
Leukaemia
Myeloma
Waldenstrom macroglubulinemia
Polycythemia
Monoclonal or type 1 cryoglobulinemia
Lung adenocarcinoma
Other paraneoplastic disorders
Environmental associations
Frostbite
Polyvinyl chloride exposure
Lead exposure
Arsenic exposure
cyanide
Metabolic/endocrine syndromes
Acromegaly
Myxedema
Diabetes mellitus
Pheochromocytoma
Fabry disease
Drugs: beta-blockers, sympathomimetic drugs with alpha receptor activity,
ergotamine, nasal decongestants, oral contraceptives, bromocriptine, cyclosporine,
alfa-interferon, antineoplastics (e.g. vinca alkaloids, bleomycin, cisplatin), cocaine
Dr. Chan Pang Fai
Investigations
CBP: polycythaemic disorders, underlying malignancies, or autoimmune disorders
RFT: renal impairment or dehydration
PT and APTT: hepatic dysfunction, antiphospholipid antibody disorders
FBG: diabetes
TSH: thyroid disorders
ANA: autoimmune disorders
Serum viscosity: hyperviscosity syndromes such as paraproteinemias
CK: polymyositis and dermatomyositis
RF: rheumatoid arthritis and other autoimmune disorders, cryoglobulinemia
Hepatitis panel
Cold agglutinins: Mycoplasma infections and lymphomas
Heavy metal screen
Growth hormone: acromegaly
Serum vanillylmandelic acid (VMA): pheochromocytoma
24hrs urine for catecholamines and VMA: pheochromocytoma
Antiphospholipid antibodies studies
Serum protein electrophoresis
References
Raynaud Phenomenon. http://emedicine.medscape.com.
Dr. Chan Pang Fai
50) Rectal bleeding

 Gastrointestinal bleeding can present in several forms, depending on the rate of
blood loss: microscopic blood loss presents as iron-deficiency anaemia or
haemoccult-positive stools; haematemesis; coffee-ground emesis; melaena,
hemochezia (passing of red blood via the rectum).
 Common causes of rectal bleeding are haemorrhoids, polyps, diverticular
disease, carcinoma of the colon and ischaemic colitis.
 Local causes of bleeding include excoriated skin anal fissure, a burst perianal
haematoma and anal carcinoma.
 Small bowel sources of gastrointestinal bleeding are uncommon, accounting for
only 2 to 10% of all cases.
 The nature of the blood (e.g. bright red, dark red or black) and the nature of the
bleeding (e.g. smear, streaked on stool, mixed with stool, massive) gives an
indication of the source of the bleeding. Black tarry (melaena) stool indicates
bleeding from the upper gastrointestinal tract and is rare distal to the lower
ileum.
 Frequent passage of blood and mucus indicates a rectal tumour or proctitis.
 Substantial haemorrhage, which is rare, can be caused by diverticular disorder,
angiodysplasia or more proximal lesions such as Meckel’s diverticulum and even
duodenal ulcers.
 Associated change of bowel habit suggests a diagnosis of carcinoma of the
rectum of left colon. Bleeding from right colon cancer is often occult, presenting
as anaemia.
 Even if there is an anal lesion, sigmoidoscopy and/or colonoscopy should be
done if there are any bowel symptoms or no obvious anal cause or a doubt
about a lesion causing the symptoms.
 Most rectal bleeding in children is benign
 The diagnostic tool of choice for all cases of upper gastrointestinal bleeding is
oesophagogastroduodenoscopy; for lower gastrointestinal bleeding, it is
colonoscopy, or arteriography if the bleeding is too brisk.
 Colonoscopy identifies definitive bleeding sites in more than 70% of patients.
But some physicians may consider a limited evaluation of the anorectosigmoid
area in patients younger than 40 years because only 5% of colorectal cancer
cases occur in this population. In addition, the most common cause of rectal
bleeding in patients younger than 30 years is anal pathology such as
haemorrhoids or fissures.
Dr. Chan Pang Fai
 If no upper gastrointestinal or large bowel source of bleeding is identified, the
small bowel can be investigated using a barium-contrast upper gastrointestinal
series with small bowel follow-through, enteroclysis, push enteroscopy,
technetium-99-tagged red blood cell scan, arteriography, or a Meckel’s scan.
Acute massive rectal bleed
Upper GI tract
Peptic ulcer disease
Gastritis/duodenitis
Oesophageal varices
Mallory-Weiss tear
Oesophagitis
Gastric cancer
Dieulafoy’s lesion: thick-walled arterial vessel surrounded by a very shallow
ulcer, usually occurs in the stomach but also occurs in the oesophagus, small
bowel, colon, and rectum
Gastric arteriovenous malformations
Portal gastropathy
Lower GI tract
Small bowel
Angiodysplasia
Jejunoileal diverticula
Meckel’s diverticulum
Neoplasms/lymphomas (benign and malignant)
Enteritis/Crohn’s disease
Aortoduodenal fistula in patient with synthetic vascular graft
Large bowel
Arterovenous malformations
Colitis: ulcerative, ischaemic
Colonic neoplasms/post-polypectomy bleeding
Anorectal causes: haemorrhoids, rectal varices
Colonic tuberculosis
Chronic intermittent rectal bleed

Upper GIT
Dr. Chan Pang Fai
Gastritis
Oesophagitis
Gastric ulcer
Duodenal ulcer
Angiodysplasia
Gastric cancer
Oesophageal cancer
Lower GIT
Small bowel
Angiodysplasia
Small bowel tumour
Small bowel ulcers or erosions
Crohn’s disease
Small bowel diverticulosis
Celiac sprue
Radiation enteritis
Small bowel varices
Lymphangioma
Blue rubber bleb nevus syndrome
Osler-Weber-Rendu syndrome
Von Willebrand’s syndrome
Small bowel polyposis syndrome
Gardener’s syndrome
Aortoenteric fistula
Amyloidosis
Haemosuccus pancreaticus haemobilia
Large bowel
Haemorrhoids
Colorectal polyps
Diverticulosis
Colorectal cancer
Proctitis/ulcerative colitis
Arteriovenous malformations
Colonic stricture
Post-polypectomy bleeding
Other colitis: ischaemic, infectious anal fissures, and radiation
Dr. Chan Pang Fai
Anal fissures
Anal neoplasms
Anal mucosal prolpase
Prolapsed rectum
Rectal bleeding in children

Neonates
Anal fissure
Necrotizing enterocolitis
Viral gastroenteritis
Midgut volvulus
Intussusception
Infants
Anal fissure
Intussuception
Gastroenteritis
Upper GI haemorrhage
Children
Anal fissure
Juvenile polyp
Inflammatory bowel disease
Intussuception
Vascular malformations
Solitary rectal ulcer
Henoch Scholein purpura
Investigations
CBP
ESR
CRP
OGD: diagnostic test of choice for suspected chronic intermittent rectal bleeding
Push enteroscopy: allows visualization of 15 to 160cm of small bowel distal to the
ligament of Treitz
Barium-contrast upper GI series with small bowel follow-through (SBFT): low
sensitivity (0-5.6%)
Dr. Chan Pang Fai
Enteroclysis: higher sensitivity than SBFT, can combined with push enteroscopy
Sigmoidoscopy: alternative in patients who have a relative contraindication to
colonoscopy
Colonoscopy: suspected lower gastrointestinal source of leading, higher sensitivity
than double-contrast barium enema in identifying colon cancer, neoplastic polyps
greater than 1cm and angiodysplasia, allows evaluation of the entire colon while
providing the opportunity to acquire tissue biopsy and facilitating therapeutic
intervention
Double-contrast barium enema: alternative in patients who have a relative
contraindication to colonoscopy
Arteriography: second-line diagnostic tool of choice for massive bleeding, also serves
a role in the evaluation of obscure sources of bleeding that are not identified by
endoscopy, particularly helpful in the evaluation of older patients in who
arteriovenous malformations or neoplasms are suspected
Technetium-99m-tagged red blood cell scan: not as accurate as arteriography
Meckel’s scan: high sensitivity (75-100%) for identifying gastric mucosa in the small
bowel, but cannot confirm the identified lesion as the source of bleeding, most
appropriately used in the evaluation of younger patients
Enhanced helical CT
Capsule endoscopy: higher diagnostic yield than push enteroscopy
References
Diagnosis of Gastrointestinal Bleeding in Adults. American Family Physician Volume
71, Number 7, April 1, 2005.
Evaluating Rectal Bleeding in Young Persons. American Family Physician, May 15,
2002.
Rectal Bleeding in Children. http://www.surgical-tutor.org.uk.
Dr. Chan Pang Fai
51) Scrotal pain

 Serious problems include testicular torsion, strangulation of an inguinoscrotal
hernia, a testicular tumour and a haematocele, all of which require surgical
intervention.
 Torsion of the testis is the most common cause of acute scrotal pain in infancy
and childhood.
 Torsion is also a feature of young men less than 25 years.
 The clinical picture of epididymo-orchitis can mimic torsion of the testis so
closely that, in most children, the diagnosis should be made only at surgical
exploration.
 Excluding mumps, no young men under the age of 18 years should be diagnosed
as suffering from acute epididymo-orchitis until the testis has been exposed at
operation and torsion excluded.
 Suspect self-correcting testicular torsion in repeated episodes of severe
spontaneously resolving pain.
 Suspect abscess formation if epididymo-orchitis does not settle with a
reasonable course of antibiotics.
 Consider dissecting aneurysm in an older person presenting with testicular pain.
 Chronic testicular pain (orchalgia) is unilateral or bilateral scrotal pain lasting for
more than three months and interfering with normal activities. The cause of
testicular pain may be difficult to determine and in approximately 25% of cases,
an underlying cause for orchalgia cannot be identified.
 Following vasectomy, pain may result from a sperm granuloma in the epididymis
or from entrapment of nerve fibers in granulation tissue.
 A varicocele can cause testicular discomfort.
 Testicular tumours are more common in young men aged 20-30 years (teratoma)
and 25-40 years (seminoma). Sometimes they can mimic an acute inflammatory
swelling and present with acute pain.
 Urinalysis should always be performed to rule out urinary tract infection in any
patient with an acute scrotum.
 Ultrasound is useful in distinguishing a cystic scrotal lump (such as a hydrocele)
from a solid tumour. Its use to distinguish between a torsion and
epididymo-orchitis is controversial. A technetium-99m scan can differentiate
between the two conditions.
Dr. Chan Pang Fai
Torsion of the testis
Torsion of a testicular appendage (e.g. the hydatid of Morgagni)
Epididymo-orchitis
Mumps orchitis
Acute hydrocele
Idiopathic scrotal oedema: usually occurs in boys aged 5-10 years, believed to be
allergic in origin, either localized or globalised as part of urticaria and the oedema is
bilateral
Haematoma/haematocele
Neoplasm: teratoma, seminoma
Henoch-Scholein purpura
Strangulated inguinoscrotal hernia
Referred pain: dissecting aneurysm, disorders of the thoracolumbar spine, notably a
disc disruption at the T12-L1 level involving the L1 nerve root
Scrotal skin conditions: e.g. sebaceous cysts
varicocele
Investigations
CBP, D/C
Chlamydia antigen detection tests such as PCR
USG and colour doppler
Technetium-99m scan
Dr. Chan Pang Fai
Patient with Acute Scrotum
Chronic Testicular Pain
References
Diagnosing Chronic Testicular Pain. American Family Physician, July 15, 2003.
Diagnosis and Treatment of the Acute Scrotum. American Family Physician, February
15, 1999.
Dr. Chan Pang Fai
52) Shortness of breath/Dyspnoea

 Appropriate breathlessness following activities such as running to catch a bus or
climbing several flights of stairs is not abnormal but may be excessive due to
obesity or lack of fitness. But it is important to be careful not to attribute
dyspnoea simply to obesity or lack of fitness when it could have a true organic
disorder such as heart failure.
 The main causes of dyspnoea are lung disease, heart disease, obesity, anaemia
and functional hyperventilation.
 The most common cause of dyspnoea encountered in family practice is airflow
obstruction, which is the basic abnormality seen in chronic asthma and chronic
obstructive pulmonary disease (COPD).
 More specifically, bronchial asthma, COPD, acute pulmonary infections and left
heart failure (often insidious) are common individual causes.
 Severe cardiovascular events such as acute heart failure, which may be
precipitated by myocardial infarction, a life-threatening arrhythmia, pulmonary
embolism, dissecting aneurysm or a cardiomyopathy (such as viral myocarditis)
require early diagnosis and corrective action.
 Pericardial tamponade may cause difficulty in diagnosis.
 Severe infections such as lobar pneumonia, tuberculosis and myocarditis must
be considered.
 Thyrotoxicosis can rarely present with dyspenoa.
 Diabetic ketoacidosis can cause rapid deep breathing.
 There are numerous causes of dyspnoea in children but the common causes are
asthma, bronchiolitis and pulmonary infections.
 In children acute epiglottitis, croup, bronchiolitis, pneumonia and bronchitis are
serious infections responsible for respiratory distress. Sudden breathlessness or
stridor may be due to an inhaled foreign body.
 Congenital heart disease can cause dyspnoea.
 Dyspnoea in the elderly is common and is cause usually by heart failure and
COPD.
 Dyspnoea is not inevitable in lung cancer but occurs in about 60% of cases.
 Interstitial pulmonary disease can be a diagnostic dilemma because the physical
signs and X-ray appearances can be minimal in the early stages despite the
presence of significant dyspnoea.
 Drugs must also be considered, especially as a cause of interstitial pulmonary
fibrosis that presents with dyspnoea, cough and fever.
Dr. Chan Pang Fai
 Various types of acute and chronic pulmonary disease are related to exposure to
noxious substances such as dusts, gases and vapours in the workplace.
 Functional dyspnoea or hyperventilation is common. However, it is important to
exclude organic causation before settling with the psychogenic label. It is
important to remember that it may be present in a patient who has organic
disease of a mild degree such as asthma.
 The history and physical examination should guide selection of initial diagnostic
tests for chronic dyspnoea such as electrocardiogram, chest radiography, pulse
oximetry, spirometry, complete blood count, and metabolic panel. If these are
inconclusive, additional testing is indicated.
 The two most important initial investigations for respiratory disease are chest
X-ray and pulmonary function tests.
 The most practical instrument for office use to detect chronic airway obstruction
due to asthma or chronic bronchitis is the mini peak flow meter, which
measures peak expiratory flow rate (PEFR).
 The measurement of the forced vital capacity (FVC) and the forced expiratory
volume in one second (FEV1) by spirometry provide a very useful guide to the
type of ventilator deficit.
 Formal pulmonary function testing may be needed to establish a diagnosis of
asthma, chronic obstructive pulmonary disease, or interstitial lung disease.
 High-resolution computed tomography (HRCT) is particularly useful for
diagnosing interstitial lung disease, idiopathic pulmonary fibrosis, bronchiectasis,
or pulmonary embolism.
 Echocardiography helps establish a diagnosis of congestive heart failure.
Bronchial asthma
Bronchiolitis (children)
Left heart failure
COPD
Obesity
Lack of fitness
Cardiovascular
Acute hear failure (e.g. AMI)
Arrhythmia
Pulmonary embolism
Pulmonary hypertension
Dr. Chan Pang Fai
Dissecting aneurysm
Cardiomyopathy
Pericardial tamponade
Anaphylaxis
Valvular heart disease
Congenital heart disease
Neoplasia
Bronchial carcinoma
Lung metastases
Lymphangitis carcinomatosis
Lymphomas
Pleural mesothelioma
Severe infections
SARS
Avian influenza
Pneumonia
Acute epiglottitis
Respiratory disorders
Inhaled foreign body
Upper airways obstruction
Pneumothorax
Atelectasis
Pleural effusion
Tuberculosis
Lung collapse
Interstitial lung disorders: cryptogenic fibrosing alveolitis, extrinsic allergic
alveolitis, sarcoidosis, connective tissue disorders, vasculitis
Chemical pneumonitis
Pneumonconiosis: coal worker’s pneumoconiosis, siderosis, silicosis, asbestosis
Occupational asthma
Acute respiratory distress syndrome (ARDS): e.g. sepsis, shock, trauma, burns,
multiple transfusions, drug overdose, eclampsia, amniotic fluid embolism, toxic
gas inhalation, blast injury, SARS
Tracheal stenosis
Neuromuscular disease
Infective polyneuritis
Poliomyelitis
Dr. Chan Pang Fai
Myasthenia gravis
Amyotrophic lateral sclerosis
Metabolic acidosis e.g. diabetic ketoacidosis
Radiotherapy
Kidney failure (uraemia)
Psychogenic: depression, anxiety, panic disorder, post-traumatic stress disorder
Drugs induced interstitial pulmonary fibrosis: bleomycin, cyclophosphamide,
methotrexate, amiodarone, sulphasalazine, penicillamine, nitrofurantoin, gold salts
and adrenergic nasal sprays
Drugs induced eosinophilic reactions: antibiotics, NSIADS, cytotoxic agents, major
tranquillisers, antidepressants, antiepileptics
Drugs induced acute pulmonary edema: opioids, aspirin, hydrochlorothiazide,
cytoxics, interleukin-2, heroin
Drugs aggravating obstructive airwary disease: beta blockers
Poisons: salicylate, methyl alcohol, theophylline overdosage, digoxin toxicity and
ethylene glycol
Thyrotoxicosis
High altitude
Chest wall deformities (kyphoscoliosis)
Gastro-oesophageal reflux disorder: reflux may stimulate vagal reflexes that inhibit
diaphragmatic function, thereby causing breathlessness
Investigations
CXR: may reveal chest wall abnormalities, lung parenchymal disease, neoplastic
lesions, congestive heart failure, or pleural disease
Lung function tests
PEFR
Spirometry
Lung volume by the helium dilution method
Gas transfer factor
Histamine challenge test
CBP: anaemia, eosinophilia of asthma, secondary erythrocytosis may be present in
patients with advanced COPD
ESR
Arterial blood gas analysis: respiratory acidosis
Cardiological investigations
ECG, including exercise
Dr. Chan Pang Fai
Echocardiography
Nuclear gated blood pool scan to assess heart function
Cardiac enzymes
HRCT
MRI
Ventilation and perfusion radionuclide scan: pulmonary emobolism
Bronchoscopy/fibre-optic bronchoscopy
Thoracocentesis and pleural biopsy
Open lung biopsy
Alpha1-antitrypsin measurement
24-hour pH monitoring
Evaluation of Patients with Chronic Dyspnoea
References
Evaluation of Chronic Dyspnoea. American Family Physician Volume 71, Number 8,
April 15, 2005.
Shortness of Breath. Australian Family Physician Volume 34, Number 7, July 2005.
Dr. Chan Pang Fai
53) Shoulder pain

 Shoulder pain is responsible for approximately 16% of all musculoskeletal
complaints.
 Virtually all shoulder structures are innervated by C5 nerve root. Pain present in
the distribution of the C5 nerve can arise from: cervical spine, upper roots of
brachial plexus, glenohumeral joint, rotator cuff tendons, biceps tendon, soft
tissue (e.g. polymyalgia rheumatica), viscera especially the heart, lungs and
sub-diaphragmatic structures.
 Shoulder pain is defined as chronic when it has been present for longer than six
months.
 Patients younger than 40 years are more likely to present with shoulder
instability or mild rotator cuff disease (impingement, tendinopathy), whereas
patients older than 40 years are at an increased risk for advanced, chronic
rotator cuff disease (partial or complete tear), adhesive capsulitis, or
glenohumeral osteoarthritis.
 Disorders of the rotator cuff are common, especially supraspinatus
tendonopathy.
 The commonest causes of pain in the shoulder zone are cervical disorders and
periarthritis (i.e. soft tissue lesions involving the tendons around the
glenohumeral joint).
 Adhesive capsulitis is the classic cause of the ‘frozen shoulder.’ It is common and
estimated to affect 2-5% of the general population and 10-20% of diabetes.
Adhesive capsulitis can also be associated with thyroid disorders.
 Fractures of the humerus, scapula and clavicle usually result from a direct blow
or a fall onto an outstretched hand.
 It is important to exclude any malignancy or septic infection, be it septic arthritis
or osteomyelitis. Carcinoma of the lung (Pancoast’s syndrome) should be kept in
mind.
 For pain in the region of the left shoulder the possibility of myocardial ischaemia
has to be considered.
 With an acute onset of painful capsulitis the possibility of rheumatoid arthritis
(or even gout) is worth considering.
 Shoulder pain in children is not a common presenting problem but the following
require consideration: septic arthritis/osteomyelitis and swimmer’s shoulder.
 Imaging studies, indicated when diagnosis remains unclear or management
would be altered, include plain radiographs, magnetic resonance imaging,
Dr. Chan Pang Fai
ultrasonography, and computed tomography scans.
 Plain radiographs may help diagnose massive rotator cuff tears, shoulder
instability, and shoulder arthritis.
 Magnetic resonance imaging and ultrasonography are preferred for rotator cuff
disorders.
Cervical spine
Dysfunction
Cervical spondylosis
Cervical radiculopathy
Acromioclavicular joint
Dysfunction
Osteoarthritis
Strain and sprain
Sternoclavicular joint
Strain and sprain
Shoulder complex
Extracapsular
Subacromial bursitis
Rotator cuff disorders: supraspinatus tendonopathy, infraspinatus
tendonopathy, subscapularis tendonopathy, impingement, tear
Biceps tendonitis
Swimmer’s shoulder
Intracapsular
Adhesive capsulitis: idiopathic, blunt trauma, diabetes
Rheumatoid inflammation: rheumatoid arthritis, ankylosing spondylitis,
psoriatic arthropathy
Osteoarthritis
Avascular necrosis
Septic arthritis
Osteomyelitis
Labral injury
Winged scapular – muscular fatigue pain
Gout/pseudogout
Neoplasia
Dr. Chan Pang Fai
Pancoast tumour
Primary or secondary in humerus
Fractures
Humerus
Scapula
Clavicle
Dislocation of the humerus
Osteolysis of the distal clavicle
Drugs
Corticosteroids can cause avascular necrosis of the humeral head
Anabolic steroids (weight-lifters) can cause osteolysis of the AC joint
Referred pain
Cardiovascular
Angina
Myocardial infarction
Pericarditis
Lung
Pneumothorax
Mediastinum, including oesophagus
Diaphragmatic irritation
Peptic ulcer and perforated ulcer
Intraperitoneal bleeding (e.g. ruptured spleen)
Herpes zoster
Parsonage Turner syndrome (brachial plexus neuritis)
Suprascapular nerve injury
Psychogenic
Investigations
ESR: polymyalgia rheumatica
RF
Serum urate
FBG
TFT
ECG
Radiology
X-ray of a specific part of the shoulder – AP view of glenohumeral joint for
degenerative glenohumeral changes, AC joint for degenerative changes and AC
Dr. Chan Pang Fai
joint separation, axillary view of glenohumeral joint for glenohumeral
dislocation and bony Bandart lesion, Shoot-through axillary views (posterior
dislocation), suprasinatus outlet (arch) for abnormality of acromion process and
degenerative changes of anterior acromion
X-ray C-spine
Radionuclide bone scan: to assess bone tumour
High-resolution USG – to assess shoulder pain due to rotator cuff lesions,
especially tears and capsulitis
Arthrogram of shoulder: good at identifying complete rotator cuff tear or
adhesive capsulitis
CT scan – may be useful in diagnosis of subtle dislocation, also preferred
imaging study for bony disorders of the shoulder, including arthritis with
significant erosion, tumours and occult fractures
MRI – a useful method but not routinely required except for the unstable joint;
95% sensitivity and specificity in detecting complete rotator cuff tears, cuff
degenerative, chronic tendonitis and partial cuff tears
MRI arthrogram: preferred test for the imaging of suspected labral pathology
that may be found in chronic shoulder instability
CT arthrogram: for patients with suspected rotator cuff tears who cannot
undergo an MRI
Arthroscopy
References
The Painful Shoulder: Part I. Clinical Evaluation. American Family Physician, May 15,
2000.
The Painful Shoulder: Part II. Acute and Chronic Disorders. American Family Physician,
May 15, 2000.
Chronic Shoulder Pain: Part I. Evaluation and Diagnosis. American Family Physician
Volume 77, Number 4, February 15, 2008.
Chronic Shoulder Pain: Part II. Treatment. American Family Physician Volume 77,
Number 4, February 15, 2008.
Dr. Chan Pang Fai
54) Subfertility/Infertility
 About 50% of normal couples, having unprotected intercourse at least twice a
week, will probably achieve pregnancy in 6 months, 80% in 1 year and 90% in 2
years.
 Infertility is defined as the absence of conception after a period of 12 months of
normal unprotected sexual intercourse.
 Evaluation generally begins after 12 months, but it can be initiated earlier if
infertility is suspected based on history or if the female partner is older than 35
years.
 Infertility affects 10-15% of all cohabitating couples.
 About 15% of couples who do not use contraception fail to achieve a pregnancy
within 12 months. More than 10% remain unsuccessful after 2 years. Only about
50% of couples will seek medical assistance.
 The main factors to be assessed are ovulation, tubal patency and semen
analysis.
 About 40-50% of couples have an identifiable male factor. Male infertility affects
5% of men. Primary hypogonadism (testicular failure or dysfunction) is the most
common identifiable cause.
 Female factors account for about 45%: tubal problems account for about 20%
and ovulatory disorders about 20%.
 Polycystic ovary syndrome (PCOS) is the most common cause of ovulatory
dysfunction.
 Investigations are usually performed after referral but the family doctor should
organize initial investigations to assess where to refer (e.g. andrologist,
endocrinologist, gynaecologist).
 The initial investigation for the man is semen analysis on two occasions. The
initial investigation for the woman is a basal body temperature chart followed
by midluteal progesterone measurement. Ovulation can also be documented
with a home urinary luteinizing hormone kit.
 Hysterosalpingography and pelvic ultrasonography can be used to screen for
uterine and fallopian tube disease.
 Hysteroscopy and/or laparoscopy can be used if no abnormalities are found on
initial screening.
 About 15% of cases have no apparent explanation.
 A significant number (25%) have combined male and female problems.
Dr. Chan Pang Fai
Female factors
Ovulation disorders
Ovarian failure (e.g. oocyte ageing, premature ovarian failure)
Stress
PCOS
Weight-related ovulation disorders
Hyperprolactinaemia
Other endocrine disorders e.g. hypothyroidism, adrenal disease
Idiopathic eugonadotropic anovulation
Tobacco use
Tubal disease
PID
Endometriosis
Previous ectopic pregnancy
Previous tubal ligation
Previous peritonitis
Uterine and cervical abnormalities
Congenital
Acquired: fibroids, polyps
Poor cervical mucus quantity/quality (caused by smoking, infection)
Endometriosis
Male factors
Reduced sperm production
Idiopathic
Primary hypogonadism (30-40%)
Androgen insensitivity
Congenital cryptochidism (maldescent)
Inflammation (e.g. mumps, orchitis)
Antispermatogenic agents
Chemotherapy
Drugs: alcohol, anabolic steroids, aminoglycoside antibiotics,
sulphasalazine, cimetidine/ranitidine, colchicines, ketoconazole,
spironolactone, methotrexate, antihypertensive drugs, narcotics,
phenytoin, nitrofurantoin, nicotine, marijuana
Irradiation
Dr. Chan Pang Fai
Heat
Klinefelter’s syndrome : congenital testicular disorder
Y chromosome defect
Secondary hyponadism (1-2%)
Androgen excess state (e.g. tumour, exogenous administration)
Congenital idiopathic hypogonadotropic hypogonadism
Estrogen excess state (e.g. tumour)
Infiltrative disorder (e.g. sarcoidosis, tuberculosis)
Multiorgan genetic disorder (e.g. Prader-Willi syndrome)
Pituitary adenoma
Trauma
Disorders of coitus
Erectile dysfunction
Psychosexual ejaculatory failure
Retrograde ejaculation: genitourinary surgery, autonomic disorders (e.g.
diabetes), congenital abnormalities
Ductal obstruction
Couple factors
Joint subfertility
Psychosexual dysfunction
Investigations
Initial investigations
Male: Semen analysis 2 or more samples with 4-6 weeks apart
Female: Ovulation status
Temperature chart and cervical mucus diary: low value
Urinary lutenizing hormone using home prediction kit
Midluteal progesterone assessment (21st day of cycle): most commonly used
first line test for ovulation, a level greeter than 6ng/mL implies ovulation and
normal corpus luteal production of progesterone
Subsequent investigations
Diagnostic laparoscopy
Further investigations
Male (if azoospermia or severe oligospermia)
Dr. Chan Pang Fai
CBP: if infection suspected
Urinalysis: if genital infection suspected
Post-ejaculatory urinalysis: if retrograde ejaculation suspected
Serum FSH and testosterone level: if FSH 2.5 times normal, indicated
irreversible testicular failure, if both hormone low suggest secondary
hyponadism
Prolactin: to rule out hyperprolactinaemia causing secondary hypogonadism
LH and inhibin: a low inhibin also indicates irreversible failure
Antispserm antibodies (in semen or serum)
Sperm function tests: if evaluation of the female partner fails to reveal a cause
Chromosome analysis: 46XXY or 46XXY/46XY
Transrectal USG: to rule out retrograde ejaculation and ejaculatory duct
obstruction
Scrotal USG: evaluate suspected testicular and scrotal abnormalities such as
hydroceles and tumours
Testis biopsy: occasionally needed to be certain whether azoospermia is due to
spermatogenic failure or obstruction
Female
TSH: ? hypothyroidism
Serum prolactin: to rule out pituitary tumour
FSH, LH, androgen levels: assessment for PCOS; women older than 25 years may
benefit from testing of FSH and estradiol levels on day 3 of their menstrual cycle
to assess ovarian reserve
Clomiphene citrate challenge test:
17α-hydroxyprogesterone and serum testosterone levels: late onset congenital
adrenal hyperplasia and adrogen-secreting tumours
Sonohysterogram
Endometrial biopsy
Transvaginal ultrasound
Hysteroscopy/laparoscopy
CT of the pituitary fossa
Chlamydia (cervical culture)
References
Infertility. American Family Physician Volume 75, Number 6, March 15, 2007.
Management of the Infertile Couple. Australian Family Physician Volume 34, Number
3, March 2005.
Dr. Chan Pang Fai
55) Tinnitus
 Tinnitus is common, affecting up to 10% of the US general population.
 Most causes of tinnitus are subjective, but occasionally the tinnitus can be
heard by an examiner.
 Otologic problems, especially hearing loss, are the most common causes of
subjective tinnitus.
 Common causes of conductive hearing loss include external ear infection,
cerumen impaction, tympanic membrane perforation, abnormalities of the
ossicular bone chain such as otosclerosis and middle ear effusion.
 Sensorineural hearing loss may be caused by exposure to excessive loud noise,
presbycusis, ototoxic medications, or Meniere’s disease.
 When pathology in the inner ear is the cause, the tinnitus is non-pulsating,
continuous and may have variable frequencies and intensity.
 Unilateral hearing loss plus tinnitus should increase suspicion for acoustic
neuroma.
 Ototoxic medications or substance are another common cause of bilateral
tinnitus. Ototoxicity may affect hair cells, the eighth cranial nerve, or their
central nervous connections.
 Subjective tinnitus also may be caused by neurologic, metabolic, or psychogenic
disorders.
 Objective tinnitus usually is caused by vascular abnormalities of the carotid
artery or jugular venous systems.
 Initial evaluation should include audiometric testing to identify and underlying
etiology.
 Diagnostic testing should include audiography, speech discrimination testing and
tympanometry.
 Unilateral or pulsatile tinnitus may be caused by more serious pathology and
typically merits specialized audiometric testing and radiologic studies.
Subjective tinnitus
Otologic
Hearing loss
Meniere’s disease
Acoustic neuroma
Ototoxic medications or substances
Dr. Chan Pang Fai
Analgesics: aspirin, NSAIDS
Antibiotics: aminoglycosides, chloramphenicol, erythromycin, tetracycline,
vancomycin
Chemotherapeutics: bleomycin, cisplatin, mechlorethamine, methotrexate,
vincristine
Loop diuretics: bumetanide, ethacrynic acid, furosemide
Others: chloroquine, heavy metals (mercury, lead), heterocyclic antidepressants,
quinine
Neurologic
Multiple sclerosis
Head injury
Temporomandibular joint disorder
Metabolic
Thyroid disorder: hyperthyroidism and hypothyroidism
Hyperlipidaemia
Anaemia
Vitamin B12 deficiency
Zinc deficiency
Psychogenic
Depression
Anxiety
Fibromyalgia
Objective tinnitus
Vascular
Arterial bruit: petrous carotid system is the most common source
Venous hum: hypertension, abnormally high placement of the jugular bulb
Arteriovenous malformation
Vascular tumours: glomus tumour arising from the paraganglia around the
carotid bifurcation, the jugular bulb, or the tympanic arteries
Neurologic
Palatomyoclonus: associated with other neurologic disorders such as brain-stem
tumour, infarction, or multiple sclerosis
Idiopathic stapedial muscle spasm
Patulous eustachian tube
Dr. Chan Pang Fai
Investigations
Audiometric assessment
Audiography: establishes a base from which to pursue more advanced
diagnostic testing, pure tone testing tests the function of the peripheral portion
of the hearing apparatus
Speech discrimination testing
Tympanometry: helps identify previously undetected middle ear effusions
changes in tympanic membrane stiffness caused by a patulous eustachian tube,
or myoclonus of the stapedial muscle or the muscles of the palate
CBP
TFT
Lipid profile
CT brain
MRI brain: the study of choice for non-pulsatile tinnitus
Diagnostic Approach to Tinnitus
References
Diagnostic Approach to Tinnitus. American Family Physician Volume 69, Number 1,
January 1, 2004.
Dr. Chan Pang Fai
56) Traveller’s fever

 Fever is among the most frequently reported problem in returning travelers.
 It is important to exclude life threatening conditions such as malaria that may be
related to the travel.
 Common tropical diseases found include malaria, dengue, enteric fever,
rickettsial infections and respiratory infections.
 In Australia, about 20-40% of travelers have respiratory symptoms while away or
on return. The most common causes are allergy and viral infection of the upper
respiratory tract.
 A significant proportion of travellers may have infections that are also common
in nontravellers.
 A complete history and examination together with initial laboratory
investigation may give a clue to the diagnosis of a tropical disease; an estimate
of the incubation period may narrow the differential diagnosis.
 Initial laboratory investigations may include: a full blood count with differential;
thick and thin blood malaria films, liver function tests, cultures of blood and
stool, urinalysis with urine culture and serological tests for arboviral or rickettsial
infections.
 Additional tests may be requested based on the history and finding of physical
examination.
Respiratory infections e.g. common cold, influenza, Legionnaire disease,
histoplasmosis, coccidoidomycosis, Q fever, avian influenza, SARS
Hepatitis
Malaria
Dengue
Mononucleosis
Japanese encephalitis
Meningococcaemia
Rickettsial infection e.g. scrub typhus, African tick bite fever, Mediterranean and
Rocky Mountain spotted fever
Salmonella typhi or Salmonella paratyphi infection
HIV
Other STDs: syphilis, gonorrhoea
Leptospirosis
Dr. Chan Pang Fai
Brucellosis
Relapsing fever e.g. Borellia spp
Viral haemorrhagic diseases: Yellow fever, Lassa fever, Marburg virus, Ebola virus,
Crimean-Congo haemorrhagic fever, Rift Valley fever, Rocky Mountain spotted fever
Visceral leishmaniasis
Amoebiasis
Kala-azar
Incubation periods of travel related infections in febrile travelers

Short Intermediate Long
(<10 days) (10-21 days) (>21 days)
Malaria Malaria Malaria
Influenza Viral haemorrhagic fever Hepatitis A, B, C, E
Arboviral infections including Typhoid fever Schistosomiasis
Dengue, yellow fever Scrub typhus (Katayama fever)
Plague Q fever Leishmaniasis
Enteric bacterial infections Relapsing fever (Borrelia spp) Amoebic liver
Including paratyphoid fever African trypnosomiasis abscess
African tick bite fever Brucellosis Tuberculosis
Spotted fever group (including Leptospirosis Filariasis
Rocky Mountain spotted fever) HIV
Investigations
CBP, D/C
Thick and thin films: malaria
ESR
LFT: hepatitis
RFT
Blood culture: typhoid fever, meningococcal infection
Stool microscopy and culture: Campylobacter, Salmonella, Shigella, Typhoid,
Amoeba, Giardiasis
Spot agglutination tests: Dengue fever, malaria
Serological tests
Dengue fever (acute and convalescent)
Typhoid fever (acute and convalescent)/Widal test
Viral hepatitis A, B
Dr. Chan Pang Fai
Amoebiasis
Typhus
Rickettsiosis (Weil Felix)
Brucella
References
Assessment of Febrile Illness in the Returned Traveller. Australian Family Physician
Volume 35, Number 5, May 2007.
Dr. Chan Pang Fai
57) Urethral discharge

 Urethral discharge is usually caused by urethritis
 Urethritis may occur in any sexually active person, but incidence is highest
among people aged 20-24 years.
 Urethritis is an inflammation condition that can be infectious or posttraumatic
in nature.
 Infectious cause of urethritis are typically sexually transmitted and categorized
as either gonococcal urethritis (GU) or non-gonococcal urethritis (NGU) (i.e. due
to infections with Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma
hominis, Mycoplasma genitalium, or Trichomonas vaginalis).
 Patients with GU have a shorter incubation period compared to those with NGU,
and the onset of dysuria and purulent discharge is abrupt.
 Rare infectious causes of urethritis include lymphogranuloma venereum, herpes
genitalis, syphilis, mycobacteria, and typical bacteria associated with cystitis in
the presence of urethral stricture.
 Post-traumatic urethritis can occur in 2-20% of patients practicing intermittent
catheterization and following instrumentation or foreign body insertion.
 Urethritis may be associated with other infectious syndromes such as
epididymitis, orchitis, prostatitis, proctitis, Reiter syndrome, iritis, pneumonia,
otitis media, or urinary tract infection.
 All patients with urethritis should be tested for Neisseria gonorrhea and
Chlamydia trachomatis.
Non-specific urethritis
Sexually transmitted disease
Gonorrhea
Chlamydia
Trichomonas
Non-gonococcal urethritis
Prostatitis
Foreign body in urethra
Mechanical urethritis: trauma or damage to the urethra from physical injury (e.g.
cycling, horse riding, excessive masturbation, etc.)
Post-traumatic urethritis
Chemical urethritis caused by spermicides
Dr. Chan Pang Fai
Reiter’s syndrome
Urethral cancer
Dried semen mistaken for discharge
Investigations
Endourethral culture for N gonorrhea and C trachomatis
Urinalysis and urine for culture: not useful except for helping exclude UTI
High vaginal swab for culture
Endocervical swab for Chlamydia culture
Polymerase chain reaction (PCR) Chlamydia urine test on first catch urine specimen
Ligase chain reaction (LCR) Chlamydia urine test: 90-95% sensitive, 100% specific
STD screening: Rapid Plasma Reagin (RPR) test for syphilis, HIV serology
ESR: elevated in Reiter syndrome
HLA-B27 testing: of limited value in diagnosis of Reiter syndrome
Retrograde urethrogram: trauma and possible foreign body insertion
Cystoscopy: foreign body
References
Urethritis. http://emedicine.medscape.com.
Penis discharge. http://www.wrongdiagnosis.com.
Dr. Chan Pang Fai
58) Urinary frequency

 Urinary frequency = urinating frequently
 The basic causes of urinary frequency can be divided into 3 groups:
 Polyuria when too much urine is being produced
 Instability of the detrusor mechanism
 Inability of the bladder to stretch
 Strictly speaking, urinary frequency occurs when there is an increased need to
urinate more often a concomitant increase in the volume of urine.
 The prevalence increases with age and is more common in women. In the
elderly it is very common in both sexes.
 The urinalysis forms an integral part of the initial diagnostic work-up. The results
of the urinalysis, along with clinical signs and symptoms, can help direct further
management by either aiding in establishing the diagnosis or directing further
investigation.
Drinking too much water, especially caffeine or alcohol
Urinary tract infection including bacterial cystitis
Chemical cystitis e.g. cyclophosphamide
Urethritis including STDs
Vaginitis or vulvar vestibulitis
Detrusor instability
Diabetes mellitus
Diabetes insipidus
Hypercalcaemia
Pregnancy
Prostate related e.g. prostatitis, benign prostatic hypertrophy, prostate cancer
Medications e.g. diuretics, doxazosin
Radiotherapy
Schistosomiasis
Bladder dysfunction
Neoplasm e.g. bladder cancer
Urinary tract stones or foreign bodies
Urethral strictures
Congestive heart failure
Dr. Chan Pang Fai
Multiple sclerosis
Parkinson’s disease
Investigations
MSU for urinalysis, microscopy and culture
Urine for pregnancy test
CBP, D/C
RFT
FBG
Ca
PSA in men
USG urinary system
KUB
IVU for ureteric stones
Bladder flow studies and cytometry
Cystoscopy
References
Frequency urination. http://www.medicinenet.com/frequent_urination/symptoms.
Urinary frequency. http://www.patient.co.uk
Frequent and urgent urination. http://.nlm.gov/medlineplus.
Dr. Chan Pang Fai
59) Urinary incontinence

 Urinary incontinence is the complaint of any involuntary leakage of urine.
 Urge incontinence is an urgent desire to void followed by involuntary loss of
urine.
 Stress incontinence is the involuntary loss of urine on coughing, sneezing,
straining or lifting, or any factor that suddenly increases intra-abdominal
pressure.
 Functional incontinence is the loss of urine secondary to factors extrinsic to the
urinary tract.
 The incidence of urinary incontinence is higher in women. Also one in five
women with urinary incontinence also experiences some degree of faecal
incontinence.
 Urinary leakage affects at least 9% of women aged 15-64 years. The most
common contributing factor is weakness of the pelvic floor.
 In most cases, a preliminary diagnosis of urinary incontinence can be made and
treatment initiated based on findings of the medical history, physical
examination and simple laboratory testing.
Stress incontinence
Sphincter incompetence
Drugs: antihypertensive/vasodilator drugs (ACEIs, phenoxybenzamine, prazosin,
labetaol)
Urge incontinence/Stress and urge incontinence/Enuresis

Impaired mobility
Unstable bladder (detrusor instability/overactivity) with or without sphincter
weakness: neurogenic (e.g. Parkinson disease, stroke, multiple sclerosis) or
idiopathic
Drugs: bladder stimulants (cholinergic agents, caffeine), sedatives (antidepressants,
antihistamines, antipsychotic, hypnotics, tranquillisers), alcohol, loop diuretics,
lithium, narcotics
Quiet dribble/Overflow incontinence

Sphincter incompetence and unstable bladder or overflow
Dr. Chan Pang Fai
Underactive bladder: e.g. diabetic neuropathy, low spinal cord injury, radical pelvic
surgery, multiple sclerosis
Outlet obstruction
Drugs: anticholinergic agents, tricyclic antidepressants, antipsychotics, beta agonists,
calcium channel blockers
Continuous leakage
Fistula
Ectopic ureter
Patulous urethra
Reflex incontinence
Neuropathic bladder
A mnemonic
D Delirium
I Infection of urinary tract
A Atrophic urethritis
P Pharmacological (e.g. diuretics)
P Psychological (e.g. acute distress)
E Endocrine (e.g. hypercalcaemia)
E Environmental (e.g. unfamiliar surrounds)
R Restricted mobility
S Stool impaction
S Sphincter damage or weakness
Investigations
Postvoid residual urine volume
RFT
FBG
Urodynamic studies: Cystometry, Uroflowmetry
Cysto-urethroscopy
Micturiting cystourethrogram
IVU
USG
Dr. Chan Pang Fai
Initial Evaluation and Work-up for Urinary Incontinence
References
Urinary Incontinence. Australian Family Physician Volume 37, Number 3, March 2008.
Urinary Incontinence in Women: Evaluation and Management. American Family
Physician, December 1, 2000.
Dr. Chan Pang Fai
60) Vaginal discharge

 It is important to make a proper diagnosis, to differentiate between normal
(physiological) and pathological discharge.
 The two most common causes of vaginal discharge are physiological discharge
and infective vaginitis. The commonest cause of infective vaginitis is bacterial
vaginosis (bacterial vaginitis, Gardnerella vaginalis or Haemophilus vaginalis)
which accounts for 40-50% of cases of vaginalis. Candida albicans is the
causative agent in 20-30% of cases while Trichomonas vaginalis cause about
20% of cases in Australia.
 The differential diagnoses should include consideration of normal discharge,
vaginitis, either infective or chemical, sexually transmitted diseases (STDs) and
urinary tract infection.
 A survey of a large family planning clinic in Australia found that 17% of women
complained of vaginal discharge.
 Vaginal discharge may present at any age but is very common in the
reproductive years.
 Vaginal discharge is a common presentation of those STDs responsible for pelvic
inflammatory diseases.
 Benign and malignant neoplasia anywhere in the genital tract may produce a
discharge. Usually it is watery and pink or blood-stained.
 A variety of preparations that can induce a sensitivity reaction. These include
deodorant soaps and sprays and contraceptive agents, especially spemicidal
creams.
 Diabetes mellitus leading to recurrent ‘thrush’, drugs causing a local sensitivity,
and urinary tract infection have to be considered.
 Most newborn girls have some normal mucoid white vaginal discharge which
usually disappears by 3 months of age. Vulvovaginitis is the most common
gynaecological disorder of childhood, the most common cause being a
non-specific bacterial infection.
 Vaginal discharge can occur in the elderly from a variety of causes, including
infective vaginitis, atrophic vaginitis, foreign bodies, poor hygiene and neoplasia.
It is important to exclude malignancy of the uterus, cervix and vagina in the
older patients.
 One of the simplest methods of making a proper diagnosis is a wet film
examination.
 Gram-stain smear and culture should be contemplated if a diagnosis cannot be
Dr. Chan Pang Fai
made on wet film.
Normal physiological discharge: newborn, ovulation, pregnancy
Poor toilet hygiene
Non-specific vulvovaginitis
Vaginitis e.g. bacterial vaginosis, streptococcal vaginosis, candidiasis, trichomonas
Atrophic vaginitis
Chemical vaginitis e.g. perfumes, condoms, tampons or sanitary napkins, spermicidal
gel, diaphragm, dyes
Infectious cervicitis: gonorrhoea, Chlamydia, herpes simplex virus
UTI
Vulvitis: trauma, scabies, neurodermatitis
Retained foreign objects e.g. tampons, IUCD
Endometriosis (brownish discharge)
Neoplasia: carcinoma, fistulas
Ectopic pregnancy (‘prune juice’ discharge)
Threadworms
Sexual abuse, esp. children
Tampon toxic shock syndrome
Investigations
pH test with paper of range 4 to 6
Amine or ‘whiff’ test: add a drop of 10% KOH to vaginal secretions smeared on glass
slide
Wet film microscopy of a drop of vaginal secretions
HVS for culture
ECS for gonorrhoea and Chlamydia
First pass urine for Chlamydia and gonorrhoea PCR
Viral culture for herpes simplex
MSU for urinalysis and culture
Pap smear
References
Management of Vulvovaginitis in Childhood. The Hong Kong Practitioner Volume 25,
July 2003.
Vaginal discharge. http://fpnotebook.com/Gyn/Vainga/Vgnts.htm.
Dr. Chan Pang Fai
61) Weight gain

 The cause of exogenous obesity is multifactorial. The end result being increased
body fatness (greater than 30% of total body weight in females and greater than
25% in males).
 The onset of obesity can occur at any age.
 The outstanding cause of weight gain in exogenous obesity is excessive calorie
intake coupled with lack of exercise.
 Secondary or pathologic causes are rare. Less than 1% of obese patients have an
identifiable secondary cause of obesity.
 Two conditions causing unexplained weight gain that can be diagnosed by the
physical examination are Cushing’s syndrome and hypothyroidism. Other
endocrine disorders that cause obesity include insulin-secreting tumours and
hypogonadism.
 After pregnancy, obesity may result from a failure to return to prepartum energy
requirements.
 It is important not to misdiagnose hypothalamic disorders, which may result in
hyperphagia and obesity. Injury to the hypothalamus may occur following
trauma and encephalitis and with a variety of tumours, including
craniopharyngiomas, optic gliomas and pituitary neoplasms.
 It is important not to overlook major organ failure and kidney disorders as a
cause of increased body weight, especially cardiac failure, liver failure and the
nephrotic syndrome. The associated increase in body water needs to be
distinguished from increased body fat.
 The rare congenital disorders that cause obesity, such as Prader-willi and
Laurence-Moon-biedl syndromes, should be easy to recognize in children.
 Without testosterone treatment, patients with Klinefelter’s syndrome become
obese as adults. Some girls with Turner’s syndrome may be short and
overweight.
 Drugs that can be an important contributing factor include tricyclic
antidepressants, corticosteroids, pizotifen, thioridazine, Depo-Provera and the
contraceptive pill.
 Obesity (overeating) may be a feature of depression. Any underlying emotional
crisis may be the reason for the overweight patient to seek medical advice.
Exogenous obesity
Dr. Chan Pang Fai
Cardiovascular
Heart failure
Hypothalamic disorders
Craniopharyngiomas
Optic gliomas
Liver failure
Nephritic syndrome
Pregnancy
Endocrine disorders
Hypothyroidism
Cushing’s syndrome
Insulinoma
Acromegaly
Hypogonadism
Hyperprolactinaemia
Polycystic ovarian disease
Frohlich’s syndrome (adiposogenital dystrophy)
Stein-Leventhal syndrome in girls
Idiopathic oedema syndrome
Klinfelter’s syndrome
Turner’s syndrome
Congenital disorders
Prader-Willi syndrome
Laurence-Moon-Biedl syndrome
Bechwith-Wiedemann syndrome
Drugs: tricyclic antidepressants, corticosteroids, pizotifen, thioridazine, Depo-Provera
and contraceptive pill
Depression
Investigations
Lipid profile
FBG
LFT
RFT
TFT
Cortisol (if hypertensive)
Testosterone: suspected sleep apnoea
Dr. Chan Pang Fai
ECG and CXR (older than 40)
References
Dr. Chan Pang Fai
62) Weight loss

 Weight loss is an important symptom because it usually implies a serious
underlying disorder, either organic or functional.
 Any loss of more than 5% of normal body weight is significant.
 The most common cause in adults of recent weight loss is stress and anxiety.
 Serious organic diseases to consider are: malignant disease, diabetes mellitus,
chronic infections (e.g. tuberculosis) and thyrotoxicosis.
 Weight loss may be a manifestation of any malignancy. With carcinoma of the
stomach, pancreas and caecum, malignant lymphomas and myeloma, weight
loss may be the only symptoms.
 Two conditions commonly associated with weight loss are anaemia and fever;
they must be excluded.
 Chronic infections to be considered include tuberculosis, infective endocarditis,
brucellosis, protozoal, systemic fungal infection and HIV infection.
 Excluding planned dietary restriction, psychological factors are the most
common cause, particularly recent stress and anxiety.
 A whole variety of gastrointestinal disorders that require consideration – these
include malabsorption states, gastric ulceration, and intestinal infestations.
 Endocrine disorders such as diabetes mellitus, hyperthyroidism, Addison’s
disease are important causes.
 Drug dependency, including alcohol and narcotic drugs, must be considered.
 Medications can cause anorexia, nausea, and vomiting or increased metabolism
leading to unintentional weight loss. Polypharmacy can cause unintended
weight loss, as can psychotropic medication reduction (i.e. by unmasking
problems such as anxiety).
 Acute or chronic infections are the most common causes of weight loss in
children beyond infancy.
 Elderly people with adverse psychological factors, neglect and possibly drug
effects can present with wasting.
 Weight loss is a common feature of depression, anxiety, anorexia nervosa.
 No cause is found in about one quarter of elderly patients with weight loss.
 A reasonable work-up includes tests dictated by the history and physical
examination, a fecal occult blood test, a complete blood count, a chemistry
panel, fasting blood glucose, a thyroid-stimulating hormone test and a
urinalysis.
 Upper gastrointestinal studies have a reasonably high yield in selected elderly
Dr. Chan Pang Fai
patients.
Stress and anxiety
Non-coping elderly
Chronic heart failure
Endocrine disorders
Diabetes mellitus
Hyperthyroidism
Hypopituitarism
Addison’s disease
Malignant disease including
Stomach
Pancreas
Lung
Myeloma
Colorectal
Lymphoma
Breast
Prostate
Chronic infection
HIV infection
Tuberculosis
Hidden abscess
Brucellosis
Urinary tract infection in children
Osteomyelitis
Chronic hepatitis
Cholecystitis
Drug dependence, esp. alcohol
Medications: e.g. SSRIs
Swallowing problems
Malabsorption states
Intestinal parasites/infestations
Celiac disease
Food intolerance
Dr. Chan Pang Fai
Inflammatory bowel diseases
Steatorrhoea
Partial or total gastrectomy
Lymphoma of the gut
Liver cirrhosis
Gastric ulcer
Chronic kidney failure
Connective tissue disorders
Dementia
Psychogenic disorders
Depression
Anorexia nervosa
“Meals on Wheels”: A Mnemonic for common treatable causes of unintentional

weight loss in the elderly
M Medication effects
E Emotional problem, especially depression
A Anorexia nervosa, alcoholism
L Late-life paranoia
S Swallowing disorders
O Oral factors (e.g. poorly fitting dentures, caries)
N No money
W Wandering and other dementia-related behaviors
H Hyperthyroidism, hypothyroidism, hyperparathyroidism, hypoadrenalism
E Enteric problems
E Eating problems (e.g. inability to feed self)
L Low-salt, low-cholesterol diet
S Stones, social problems (e.g. isolation, inability to obtain preferred foods)
Investigations
CBP, D/C: infection, deficiency anaemia, lymphoproliferative disorder
ESR
TFT
FBG
CXR
LFT: liver diseases, hypoalbuminaemia
RFT
Dr. Chan Pang Fai
HIV test
Urinalysis: evidence of infection, renal dysfunction
Stool for ova and cysts
Upper GIT: barium meal or endoscopy
Colonoscopy
References
Evaluating and Treating Unintentional Weight Loss in the Elderly. American Family
Physician, February 15, 2002.
Unintentional Weight Loss. http://www.wiserwiki.com.
Dr. Chan Pang Fai
63) Wrist and hand pain

 Osteoarthritis of the hand and tenosynovitis, such as trigger thumb or finger, are
more common with advancing age.
 Osteoarthritis commonly involved the interphalangeal joints of the fingers
especially the DIP joints and the carpometacarpal joint of the thumb.
 In rheumatoid arthritis the DIP joints are often spared (only about 30% involved)
but the metacarpophalangeal and proximal interphalangeal joints and wrist
joints are generally affected symmetrically and bilaterally.
 Gout may involve normal joints of the hand but is encountered more frequently
in osteoarthritic joints of the hand in elderly people taking diuretics.
 A similar appearance to rheumatoid arthritis occurs except that with psoriatic
arthritis the terminal joints are often involved with swelling.
 SLE and viral polyarthritis target mainly PIP joints.
 Haemochromatosis targets second and third MCP joints.
 Carpal tunnel syndrome (CTS) is seen in many work situations requiring rapid
finger and wrist motion under load.
 Trigger finger or thumb has a reported lifetime risk of 2.6% in the population
and is more common in the 5th and 6th decades of life. It is associated with type
1 diabetes, rheumatoid arthritis, gout, hypothyroidism and amyloidosis.
 After excluding CTS, trigger thumb/finger, de Quervain’s tenosynovitis,
rheumatoid and related disease, tendonitis is uncommon in the hand.
Tendonitis may occur in other extensor compartments of the wrist and hand
with unusual repetitive stressful actions.
 A mechanical cause of wrist pain is suggested when the wrist has sustained a
specific trauma.
 Patients often present with persistent wrist pain following trauma, such as a
fracture, sprain to the wrist or even a seemingly mild strain, such as falling down
with the wrist flexed into the hand. An undiagnosed fracture, ischaemic necrosis
or unstable ligamentous injury should be investigated by radiology or referral
where appropriate.
 Ischaemic necrosis particularly of the scaphoid, can occur following failure to
recognize a fracture. In children, chronic pain in the region of the lunate
suggests avascular necrosis – Kienbock’s disease, presenting with dorsal wrist
pain.
 About 60-70% of ganglions occur on the dorsal aspect of the wrist. The vast
majority arise from the dorsal scapholunate ligament. Pain can result from
Dr. Chan Pang Fai
compression on and adjacent nerve or joint space.
 Painful vascular disorders, which are more likely to occur in women in cold
weather, include Raynaud’s phenomenon, erythermalgia, chilblains and acute
blue fingers syndrome.
 The hand can be affected by the complex regional pain syndrome (reflex
sympathic dystrophy or Sudeck’s atrophy).
 Radiography is the first-line imaging modality for wrist pain, although it is not
always indicated. Posterior-anterior (PA) and lateral radiographic views are
essential to evaluate the bony architecture and alignment of the wrist, the
width and symmetry of the joint spaces, and the soft tissues.
 When a scaphoid fracture or nonunion is suspected, a scaphoid view should be
obtained in addition to routine views. Unfortunately, 20% of radiographs are
initially negative for scaphoid fractures regardless of the view. When a fracture
of the hook of the hamate is suspected, physicians should include the carpal
tunnel and supinated oblique views.
 If the diagnosis remains unclear after radiography, or if the clinical course does
not improve with conservative measures, further imaging modalities are
indicated.
 Ultrasonography is a quick and accessible way to assess soft-tissue
abnormalities such as tendon injury, synovial thickening, ganglia, and synovial
cysts.
 Bone scans can detect osteoblastic activity and can identify early stress injuries
and can effectively rule out a scaphoid fracture.
 MRI may be equally sensitive and more specific than a bone scan. MRI is more
effective in evaluating soft tissue injuries.
 CT scan can evaluate fractures and articular subluxations not identified by
routine radiography.
Overuse tendonitis of the wrist
Trigger finger/thumb (flexor tenosynovitis)
DeQuervain’s tenosynovitis (Washerwoman’s sprain)
Carpal tunnel syndrome
Osteoarthritis of thumb, carpometacarpal and DIP joints
Rheumatic arthritis
Seronegative arthropathies
Connective tissue disorders
Dr. Chan Pang Fai
Gout
Viral polyarthritis
Intersection syndrome: a bursitis develops at the site where the extensor pollicis
brevis and abductor pollics longus tendons cross over the extensor carpi radialis
tendons.
Infections of the tendon sheath and fascial spaces of hand
Entrapment neuropathies (e.g. median nerve, ulnar nerve)
Bone tumours
Benign: giant cell tumour of the tendon sheath, pigmented villonodular
synovitis, nerilemmoma and neurofibroma
Malignant: synovioma, rhabdomyosarcoma
Fractures
Ligament injury: scapholunate and lunotriquetral ligaments
Triangular fibrocartilage complex (TFCC) injury
Distal radioulnar joint subluxation
Carpal instability
Scapholunate dissociation
Post-traumatic chronic wrist pain
Avascular necrosis of scaphoid (Preiser’s disease)
Kienbock’s disease (Avascular necrosis of lunate)
Ganglion
Peripheral neuropathy
Osteomyelitis
Neurovascular disorders of the hand
Raynaud’s phenomenon
Erythermalgia
Acute blue fingers syndrome in women
Chilblains (perniosis)
Radiating pain from cervical disc lesion
Haemochromatosis
Causes or associations of carpal tunnel syndrome

Idiopathic
Trauma
Fibrosis
Granulomatous disorders (TB, etc)
Dr. Chan Pang Fai
Acromegaly
Amyloidosis
Pregnancy
Premenstrual oedema
Hypothyroidism
Paget’s disease
Diabetes mellitus
Tophaceous gout
Infections of the hand

Infected wound with superficial cellulites or lymphangitis
Subcutaneous tissue
Nail bed (paronychia)
Pulp (whitlow, e.g. herpes simplex)
Erysipeloid
Tendon sheath infection (suppurative tenosynovitis)
Deep palmar fascial space infection
Sporotrichosis (gardener’s arm)
Investigations
CBP, D/C
ESR
RF
ANA
X-ray
NCT
Electromyography
USG
CT
Technetium bone scan
Arthrograms
Arthroscopy
References
A Clinical Approach to Diagnosing Wrist Pain. American Family Physician, November
1, 2005
Dr. Chan Pang Fai
Hand and Wrist Injuries: Part I. Nonemergent Evaluation. American Family Physician,
April 15, 2004
Hand and Wrist Injuries: Part II. Emergent Evaluation. American Family Physician,
April 15, 2004

DDX & Ix Guide For Common Symptoms in Primary Care KEC 2010 PDF

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Differential Diagnosis and Investigation Guide for

Common Symptoms and Signs in Primary Care

Dr. Chan Pang Fai

Red flags for organic disease

Conditions where evidence is inconclusive for diagnosis and treatment of H. Pylori

Chronic or recurrent abdominal pain in children (10% of school-aged

Red flags for organic disease

2) Amenorrhoea and Oligomenorrhoea

Differential diagnosis for secondary amenorrhoea or oligomenorrhoea

Evaluation of Secondary Amenorrhea

Recommendation from Practical General Practice:

5) Blackout and syncope

Causes of syncope can also be categorized as follows:

7) Change in bowel habit

Irritable bowel syndrome

Outpatient Diagnosis of Chest Pain

Clinical finding* Points

Clinical signs and symptoms of DVT (i.e., objectively measured 3.0

leg swelling or pain with palpation of deep leg veins)

PE as likely or more likely than an alternative diagnosis 3.0

Heart rate more than 100 beats per minute 1.5

Immobilization (i.e., bedrest except for bathroom access 1.5

for at least three consecutive days) or surgery in the past

Previous objectively diagnosed DVT or PE 1.5

Malignancy (treatment for cancer that is ongoing, within the 1.0

past six months, or palliative)

Total points Risk of PE LR+ 21

< 2 points Low 0.13 1 to 28

2 to 6 points Moderate 1.82 28 to 40

> 6 points High 6.75 38 to 91

Differential diagnosis (children)

Sequential approach to the evaluation of chronic cough in the immunocompetent adult.

12) Dizziness and Vertigo

14) Dyspepsia (Indigestion)

Rome II diagnostic criteria for functional dyspepsia

Evaluation and management of non-ulcer dyspepsia.

Evaluation of Acute Dysuria*

stage of the evaluation to confirm or rule out an infectious process

17) Foot, ankle and heel pain

Ankle and hindfoot

Ottawa rules for ankle and foot x-ray

hCG: The β subunit of human chorionic gonadotropin is secreted also by some

Alport's syndrome Vascular disease

Fabry's disease Arteriovenous malformation

Goodpasture's syndrome Malignant hypertension

Poststreptococcal glomerulonephritis Coagulopathy related

Wegener's granulomatosis Secondary to systemic disease

Nonglomerular causes Congenital abnormalities

Infection: pyelonephritis, tuberculosis (e.g., travel to Indian subcontinent), Perineal irritation

schistosomiasis (e.g., travel to Africa) Posterior ureteral valves

Interstitial nephritis Strictures

Drug induced: penicillins, cephalosporins, diuretics, nonsteroidal Transitional cell carcinoma of

(Thorazine), anticonvulsants Trauma: catheterization, blunt

Infection: syphilis, toxoplasmosis, cytomegalovirus, Epstein-Barr virus trauma

Systemic disease: sarcoidosis, lymphoma, Sjögren's syndrome Tumor

Loin pain-hematuria syndrome Other causes

Metabolic: Hypercalciuria, Hyperuricosuria Exercise hematuria

Renal cell carcinoma Menstrual contamination

Solitary renal cyst Sexual intercourse

Algorithmic approach to microscopic hematuria in adults. (CVA = costovertebral

angle; RBC = red blood cell.)

Algorithm for diagnosing nonmassive hemoptysis. (CT = computed tomography.)

Conditions of the urethra