GP LAND

Secondary causes

May 28, 2024 / No Comments


Hypertension

  1. Essential (90-95%)
  2. Secondary – Kidney
    • GN
    • Reflux nephropathy
    • Renovascular hypertension (renal artery stenosis, chronic kidney disease (diabetes, PCKD))
  3. Endocrine
    • Hyperthyroidism and Hypothyroidism
    • Primary Hyperaldosteronism (Conns Syndrome)
      • Morning Aldosterone to aldosterone-to-renin ratio (ARR)
      • Ratio over 20-25 (esp if >100) suggests Hyperaldosteronism
    • Hypercortisolism (Cushing’s disease)
    • Phaeochromocytoma (frequent headaches, sweating, palpitations)
  4. Coarctation of aorta
  5. Other
    • Pregnancy
    • Anemia
    • Obstructive sleep apnea (obesity, snoring, daytime sleepiness)
    • Immunological disorders (PAN)
  6. Medications
    • OCPs, NSAIDs
    • Clozapine
    • Steroids
    • Cyclosporine
    • Tacrolimus
    • MAO-I
    • SSRI/SNRI’s (venlafaxine, paroxetine, desvenlafaxine, reboxetine)
    • Pseudoephedrine
    • Amphetamines (duramine)

Syncope

  1. Neurally Mediated Syncope
    • Vasovagal syncope (Provoked by pain, fear, emotion, venesection)
    • Situational syncope (Provoked by coughing, micturition, defecation)
    • Carotid Sinus Syncope (Neck rotation or pressure, e.g., tight collar)
  2. Orthostatic Hypotension
    • Primary autonomic failure (Lewy body disease, Parkinson, multiple system atrophy)
    • Secondary autonomic failure (Diabetic neuropathy, amyloid neuropathy, HIV neuropathy)
    • Postprandial hypotension
    • Postural Tachycardia Syndrome (POTS) (Most common in young women)
    • Drug-induced (anti-hypertensives, diuretics, antidepressants)
    • Volume loss (hemorrhage, diarrhea, Addison’s disease)
  3. Cardiac Syncope
    • Arrhythmias (Sinus node dysfunction, atrioventricular conduction system disease, paroxysmal supraventricular and ventricular tachycardias, inherited syndromes, implanted device malfunction, drug-induced proarrhythmias)
    • Structural cardiac disease (valvular heart disease, aortic stenosis, ischemic heart disease, cardiomyopathy, pericardial disease)
  4. Vascular Disorders
    • Aortic dissection
    • Abdominal aortic aneurysm rupture
    • Pulmonary embolism
    • Pulmonary hypertension
    • Subarachnoid hemorrhage
    • Subclavian steal syndrome (provoked by use of arms)
  5. Neurological
    • Seizures
    • Migraine
    • Transient ischemic attacks
    • Stroke
  6. Other
    • Metabolic disorders (hypoglycemia, hypoxia, hyperventilation with hypocapnia)

Categories of Dizziness

  1. Vertigo = Spinning Sensation
    • Vestibular pathology (Vestibular neuritis, labyrinthitis, Meniere’s disease)
  2. Presyncope = Fainting Sensation
    • Reduced cerebral perfusion (volume depletion, neurocardiogenic syncope)
  3. Dysequilibrium = Imbalance Sensation
    • Gait disorder (myelopathy, peripheral neuropathy, Parkinson’s disease)
  4. Light-headedness = Sensation of Disconnection from the Environment
    • Psychological disorder (anxiety, depression)

Chest Pain

  1. Life-Threatening Diagnoses
    • Acute coronary syndrome (acute myocardial infarction, unstable angina pectoris)
    • Pulmonary embolism
    • Aortic dissection
    • Spontaneous pneumothorax
  2. Chronic Conditions Requiring Urgent Evaluation
    • Angina pectoris due to stable coronary artery disease
    • Aortic stenosis
    • Aortic aneurysm
    • Lung cancer
  3. Other Acute Conditions
    • Acute pericarditis
    • Pneumonia or pleurisy
    • Herpes zoster
    • Peptic ulcer disease/Gastroesophageal reflux
    • Acute cholecystitis
  4. Other Diagnoses
    • Neuromusculoskeletal causes
    • Psychological causes (palpitations)

Palpitations

  1. Nonarrhythmic Cardiac Causes
    • Atrial or ventricular septal defect
    • Cardiomyopathy
    • Congenital heart disease
    • Congestive heart failure
    • Mitral valve prolapse
    • Pacemaker-mediated tachycardia
    • Pericarditis
    • Valvular disease (e.g., aortic insufficiency, stenosis)
  2. Psychological Cases
    • Anxiety disorder
    • Panic attacks
  3. Drugs and Medications
    • Alcohol
    • Caffeine
    • Certain prescription and over-the-counter agents (e.g., digitalis, phenothiazine, theophylline, beta agonists)
    • Street drugs (e.g., cocaine)
    • Tobacco
  4. Extracardiac Causes
    • Anemia
    • Electrolyte imbalance
    • Fever
    • Hyperthyroidism
    • Hypoglycemia
    • Hypovolemia
    • Pheochromocytoma
    • Pulmonary disease
    • Vasovagal syndrome

Common Findings and Suggested Diagnoses

Symptoms Potential Causes
Single ‘skipped’ beats Benign ectopy
Feeling of being unable to catch one’s breath Ventricular premature contractions
Single pounding sensations Ventricular premature contractions
Rapid, regular pounding in neck Supraventricular arrhythmias
Palpitations that are worse at night Benign ectopy or atrial fibrillation
Palpitations associated with emotional distress Psychiatric etiology or catecholamine-sensitive arrhythmia
Palpitations associated with activity Coronary heart disease
Rapid palpitations with exercise Supraventricular arrhythmia, atrial fibrillation
Positional palpitations Atrioventricular nodal tachycardia, pericarditis
Heat intolerance, tremor, thyromegaly Hyperthyroidism
Palpitations since childhood Supraventricular tachycardia
Rapid, irregular rhythm Atrial fibrillation, tachycardia with variable block
Palpitations terminated by vagal maneuvers Supraventricular tachycardia
Heart murmur Heart valve disease
Midsystolic click Mitral valve prolapse
Friction rub Pericarditis
Symptoms proceeded by postural change or micturition Orthostatic hypotension or micturition syncope
Exercise induced symptoms Aortic stenosis or supraventricular tachycardia (SVT)
Syncope during swimming Prolonged QT syndrome

Electrocardiographic Signs and Implications

  • Pre-excitation/delta wave: WPW – AVRT
  • Left atrial enlargement, frequent PACs, sinus bradycardia: Atrial fibrillation
  • Left ventricular hypertrophy: Atrial fibrillation, ventricular tachycardia
  • Frequent PVCs: Ventricular tachycardia
  • Q waves: Ischemic heart disease – atrial fibrillation, ventricular tachycardia
  • Widespread T wave inversion, LVH, Q waves, and ST-segment changes: Hypertrophic cardiomyopathy – risk of atrial fibrillation, ventricular tachycardia
  • Long or short QT interval, Brugada pattern, early repolarization pattern: Genetic arrhythmia syndromes – risk of sudden cardiac death
  • Inverted T waves or Epsilon waves across right precordial leads (V1–V3): Epsilon Waves (Arrhythmogenic Right Ventricular Dysplasia (ARVD)) – risk of sudden cardiac death

Pericarditis

  • Viral: Adenovirus, Coxsackievirus (most common viral cause), Cytomegalovirus (CMV), Epstein-Barr Virus (Mononucleosis), Influenza, HIV, Mumps/Measles/Varicella, Viral Hepatitis
  • Bacterial: Staphylococcus aureus (high mortality), Streptococcus Pneumoniae, Haemophilus Influenzae, Mycobacterium tuberculosis (most common cause in developing countries), Salmonella, Meningococcus, Syphilis, Whipple Disease, Rickettsia
  • Fungal and Parasitic
  • Autoimmune: Systemic Lupus Erythematosus, Rheumatoid Arthritis, Ankylosing Spondylitis, Sarcoidosis, Scleroderma, Rheumatic Fever, Inflammatory Bowel Disease, Wegener’s Granulomatosis, Familial Mediterranean fever
  • Neoplastic: Metastatic (Breast Cancer, Lung Cancer, Leukemia, Lymphoma, Malignant Melanoma), Primary (Sarcoma, Mesothelioma), Cancer treatment complications
  • Post-procedural: Common after cardiac or thoracic surgery

Atrial Fibrillation

  • Risk Factors and Disease Associations
    • Obesity, Hypertension, Type 2 diabetes/impaired glucose tolerance, Smoking, Obstructive sleep apnea, Coronary artery disease, Valvular heart disease, Heart failure, Chronic kidney disease, Hyperthyroidism, Alcohol excess
  • Potentially Reversible Precipitants
    • Electrolyte abnormalities, Sepsis, Anemia, Medications

Rheumatic Fever

  1. Differentials
    • Septic arthritis, Reactive arthritis, Viral arthritis, Juvenile idiopathic arthritis, Rheumatoid arthritis, IBD, SLE, vasculitis, sarcoidosis, Haemarthrosis, MSK injury/trauma, Gout/pseudogout, Non-accidental injury
  1. Diagnosis & Investigations
    • Confirm Diagnosis using Jones’ Criteria
    • Definite initial episode of ARF: 2 major or 1 major + 2 minor + evidence of preceding GAS
    • Definite recurrent episode of ARF in a patient with known past ARF or RHD: 2 major or 1 major and 1 minor or 3 minor manifestations + evidence of a preceding GAS infection

Major Criteria:

  • Carditis, Arthritis (High Risk Groups: Aseptic monoarthritis, Low Risk Groups: Polyarthritis), Chorea, Erythema marginatum, Subcutaneous nodules

Minor Criteria:

  • Arthritis (High Risk Groups: Monoarthralgia, Low Risk Groups: Polyarthralgia or aseptic monoarthritis), Fever, Elevated ESR/CRP, Prolonged PR interval on ECG

Evidence of preceding streptococcal infection:

  • Positive throat culture for GA β-haemolytic strep or Positive rapid streptococcal antigen test or Elevated or rising streptococcal antibody titer (most often antistreptolysin O, others include anti-DNAse B, streptokinase, antihyaluronidase)

Myocarditis

Causes (HIGAAP):

  • Hypersensitivity, Infectious/infiltrative (haemochromatosis or amyloidosis), Giant cell myocarditis, Autoimmune (SLE, polymyositis, scleroderma, sarcoid), Active viral (Coxsackie B, HIV), Post viral (lymphocytic) – (rheumatic fever), mRNA Covid19 Vaccine

DVT/PE

Major (relative risk 5-20) – SLOMMP:

  • Surgery (major abdominal/pelvic, hip/knee replacements, post ICU)
  • Lower limb problems (#, varicose veins)
  • Obstetrics (late pregnancy, C/S, puerperium)
  • Malignancy (abdominal/pelvic, advanced/metastatic)
  • Mobility (hospitalization, institutional care)
  • Previous VTE

Minor (relative risk 2-4) – COM:

  • Cardiovascular (congenital heart disease, CHF, HT, superficial venous thrombosis, CVL)
  • Oestrogens (OCP, HRT)
  • Miscellaneous (COPD, neurological disability, occult malignancy, thrombotic disorder, long distance travel, obesity, IBD, nephrotic syndrome, dialysis, myeloproliferative disorders, paroxysmal nocturnal haemoglobinuria, Bechet’s disease)

Thrombophilias:

  • Factor V Leiden mutation, Prothrombin gene mutation, Hyperhomocysteinemia, Antiphospholipid antibody syndrome, Deficiency of antithrombin III, protein C or protein S, High concentrations of factor VIII or XI, Increased lipoprotein (a)

Dilated Cardiomyopathy

  1. Ischaemic
    • Dilated cardiomyopathy commonly occurs following massive anterior STEMI due to extensive myocardial necrosis and loss of contractility
  2. Non-ischaemic
    • Most cases are idiopathic
    • Up to 25% are familial (primarily autosomal dominant, some types are X-linked)
    • A very small proportion may occur with:
      • Viral myocarditis (coxsackie B / adenovirus)
      • Alcoholism
      • Toxins (e.g. doxorubicin)
      • Autoimmune disease
      • Pregnancy (peripartum cardiomyopathy)

Secondary Dyslipidemia

  1. Hypothyroidism
  2. Hyperparathyroidism
  3. Renal impairment
  4. Nephrotic syndrome
  5. Cholestasis
  6. Anorexia nervosa
  7. Cushing’s syndrome
  8. Type 2 diabetes
  9. Obesity
  10. Smoking
  11. Alcohol use
  12. Medications:
    • Oestrogen use (higher dose COCP)
    • Antipsychotics
    • Anabolic steroids
    • Beta blockers
    • Tamoxifen

Claudication

  1. Vasculitides:
    • Takayasu arteritis (Asian females, 15–45 years)
    • Thromboangiitis obliterans (20–40 years, significant history of cigarette smoking)
  2. Raynaud syndrome
  3. Fibromuscular dysplasia (middle-aged women)
  4. Popliteal aneurysm
    • Blue toe syndrome: small vessel occlusion caused by embolus
  5. Arterial embolism
  6. Popliteal entrapment syndrome
  7. Deep Vein Thrombosis (DVT)
  8. Spinal stenosis
  9. Diabetic neuropathy

Cough: Age-Specific Causes

Pediatric

  1. Reflux
  2. Asthma
  3. URTI/Croup
  4. Bronchitis
  5. Pertussis
  6. Cystic Fibrosis (CF)
  7. Foreign Body (FB) inhalation
  8. Pneumonia

Adolescent/Young Adult (YA)

  1. Asthma
  2. Psychogenic cough
  3. Smoking
  4. Infection

Middle Age

  1. Smoking/Irritants
  2. Gastroesophageal Reflux Disease (GORD)
  3. Lung cancer
  4. Drugs (e.g., ACE inhibitors)
  5. Anxiety
  6. Infection

Elderly

  1. Infection
  2. Chronic Obstructive Pulmonary Disease (COPD)
  3. Lung cancer
  4. Drugs (e.g., ACE inhibitors)

Cough : Most Likely Causes

  1. URTI
  2. Post-nasal drip
  3. Smoking
  4. Acute bronchitis
  5. Chronic bronchitis

Cough : Not to be Missed

  1. Heart failure
  2. Lung cancer
  3. Severe infections (e.g., TB, Pneumonia, HIV)
  4. Asthma
  5. Cystic Fibrosis (CF)
  6. Foreign Body (FB) inhalation
  7. Pneumothorax (PTX)

Spasmodic Cough, Paroxysmal Cough, Coughing Fits

  1. Obstructive Lung Disease
    • Asthma or other bronchospasm
    • Bronchiectasis
  2. Infectious Causes
    • Pertussis (Whooping Cough)
    • Chlamydial Pneumonia (Staccato Cough)
    • Croup
  3. Miscellaneous Causes
    • Vocal Cord Dysfunction
    • Gastroesophageal Reflux Disease (GORD)
    • Postnasal drainage (Sinusitis, Allergic Rhinitis)

Often Missed

  1. Atypical pneumonia
  2. Nocturnal GORD
  3. Smoking
  4. Bronchiectasis
  5. Pertussis

Masquerades

  1. Drugs (e.g., ACE inhibitors, β blockers, inhaled steroids)


Shortness of Breath (SOB)

Respiratory Causes

  1. Airways Disease
    • Chronic bronchitis and emphysema
    • Asthma
    • Bronchiectasis
    • Cystic fibrosis
    • Laryngeal or pharyngeal tumor
    • Bilateral cord palsy
    • Tracheal obstruction or stenosis
    • Tracheomalacia
    • Crico-arytenoid rheumatoid arthritis
  2. Parenchymal Disease
    • Pneumonia
    • Allergic alveolitis
    • Sarcoidosis
    • Fibrosis and diffuse alveolitis
    • Diffuse infections
    • Respiratory distress syndrome
    • Infiltrative and metastatic tumor
    • Pneumothorax
    • Pneumoconiosis
  3. Pulmonary Circulation
    • Pulmonary embolism
    • Chronic thromboembolic pulmonary hypertension
    • Pulmonary arteriovenous malformation
    • Pulmonary arteritis
  4. Chest Wall and Pleura
    • Effusion or massive ascites
    • Pleural tumor
    • Fractured ribs
    • Ankylosing spondylitis
    • Kyphoscoliosis
    • Neuromuscular diseases
    • Bilateral diaphragmatic palsies

Cardiac Causes

  • LVF (Left Ventricular Failure)
  • Mitral valve disease
  • Cardiomyopathy
  • Pericardial effusion or constrictive pericarditis
  • Intracardiac shunt

Other Causes

  • Anemia
  • Non-cardiorespiratory: Psychogenic
  • Acidosis (compensatory respiratory acidosis)
  • Hypothalamic lesions

Wheeze

  • Varies According to Age
    • Viral bronchiolitis < 2 yrs
    • Asthma > 2 yrs
    • Pneumonia (bacterial, atypical)
    • Foreign body (esophageal or aspirated)
    • Laryngotracheomalacia
    • Gastroesophageal reflux
    • Congestive cardiac failure
    • Allergic reaction
    • Congenital abnormalities
    • Vascular ring
    • Bronchogenic cyst
    • Tracheoesophageal fistula
    • Mediastinal mass (e.g. lymphadenopathy)
    • Cystic fibrosis

Nasal Obstruction

  • Common Causes
    • Rhinitis (Allergic and Non-allergic: infectious/vasomotor/rhinitis medicamentosa)
    • Chronic rhinosinusitis +/- nasal polyposis
    • Inferior turbinate hypertrophy
    • Septal deviation
    • Adenoid hypertrophy
    • Dry nasal mucosa
    • Medications:
      • Antithyroid medication
      • Oral contraceptives and other estrogens
      • Antihypertensive agents (beta blockers, calcium channel blockers, ACE inhibitors, angiotensin-2 receptor blockers, phosphodiesterase 5 inhibitors)
      • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Uncommon Causes
    • Internal/external nasal valve incompetence
    • Neoplasm:
      • Benign (e.g. hemangioma, papilloma)
      • Malignant (e.g. nasopharyngeal carcinoma, squamous cell carcinoma, melanoma)

Pneumothorax

  • Secondary Pneumothorax
    • Chronic Obstructive Pulmonary Disease (COPD) (70% of secondary causes) (Related to Pulmonary Blebs)
    • Asthma (Related to marked thoracic pressure changes)
    • Tuberculosis and abscess (most common cause worldwide)
    • Cystic Fibrosis (lifetime risk of 8-20%)
    • AIDS (risk: 2-6%, typically associated with comorbid Pneumocystis jiroveci pneumonia)
    • Pneumonia
    • Bronchitis
    • Connective Tissue Disease (Marfan Syndrome, Ehlers-Danlos)
    • Valsalva or Muller Maneuver (Drug smokers, vaping)

Tuberculosis (TB) Risk Factors

  • Progression to Disease
    • Immunocompromise:
      • HIV infection (highest risk for the progression of latent infection to active TB)
      • Silicosis
      • End-stage renal disease
      • Malignancies (head and neck cancers, lymphomas)
      • Diabetes mellitus
      • Chronic malnutrition
      • Rapid weight loss
      • Chronic treatment with corticosteroids and other immunosuppressive drugs
      • Tobacco smokers
    • Intensity of exposure
    • Age at infection (risk higher in those infected in infancy, adolescence, or old age)

OM – antibiotics within 48 hrs if: Patients who should be considered for immediate treatment with antibiotics: <6 months old lmmunocompromlsed Aboriginal or Torres Strait Islander children Only hearing ear Child has a cochlear implant · Possible suppurative complication •ChatGPT

Otitis Media (OM) – Antibiotic Treatment within 48 Hours

Patients who should be considered for immediate treatment with antibiotics:

  1. Age-Related
    • < 6 months old
  2. Health Status
    • Immunocompromised
  3. Ethnicity
    • Aboriginal or Torres Strait Islander children
  4. Hearing Considerations
    • Only hearing ear
    • Child with a cochlear implant
  5. Complications
    • Possible suppurative complication

Recurrent Otitis Media (OM)

Definition:

  • 3 or more episodes in 6 months, or 4 episodes in 12 months

Risk Factors:

  1. Child care attendance
  2. Allergic rhinitis
  3. Adenoid disease
  4. Structural abnormalities (e.g., cleft palate, Down syndrome)
  5. Exposure to smoke
  6. Socioeconomic disadvantage (e.g., crowding)

High-Risk Indigenous Factors:

  1. Lives in remote communities
  2. Less than 2 years of age
  3. First episode of OM before 6 months of age
  4. Family history of chronic suppurative otitis media (CSOM)
  5. Current or previous tympanic membrane (TM) perforation
  6. Craniofacial abnormalities
  7. Cleft palate, Down syndrome
  8. Immunodeficiency
  9. Cochlear implants
  10. Developmental delay
  11. Hearing loss
  12. Severe visual impairment

Eustachian Tube Dysfunction (ETD)

Description:

  • Blocked/abnormal opening prevents air entry, causing the eardrum to be pushed in and tense, leading to dysfunction.

Causes:

  1. Upper respiratory tract infection (URTI)
  2. Allergic rhinitis
  3. Smoke exposure
  4. Air pollutants
  5. Enlarged adenoids

Clinical Features:

  1. Hearing loss
  2. Sensation of fullness in the ear
  3. Occasionally pain
  4. Tinnitus
  5. Popping noises

Treatment:

  1. Usually no specific treatment required
  2. Clear nasal passages – steam inhalations
  3. Autoinsufflation (e.g., Valsalva maneuver)
  4. Consider decongestants (if indicated)

Epistaxis (Nosebleed)

Classification:

  • 90% are anterior: arise from the anterior nasal septum at Little’s area (contains Kesselbach’s plexus).
  • 10% are posterior: generally more difficult to control, prone to airway compromise.

Causes:

  1. Idiopathic: Large majority.
  2. Local:
    • Nose picking
    • Nasal or sinus infections
    • Septal abnormality
    • Tumors (benign and malignant)
    • Foreign bodies (especially in children)
  3. Environmental:
    • Worse in winter due to dryness
    • Prolonged inhalation of dry air (Oxygen)
  4. Drugs:
    • Anticoagulants
    • Antiplatelets
    • Solvent inhalation (huffing)
    • Cocaine
  5. Iatrogenic:
    • Nasogastric tube insertion
    • Nasotracheal intubation
  6. Coagulopathies:
    • Inherited coagulopathies: von Willebrand disease, hemophilia A & B
    • Splenomegaly
    • Thrombocytopenia
    • Platelet disorders
    • Liver disease
    • Renal failure
    • Chronic alcohol abuse
    • AIDS
  7. Vascular Abnormalities:
    • Sclerotic vessels
    • Hereditary hemorrhagic telangiectasia
    • Arteriovenous malformation
    • Neoplasm
    • Aneurysms
    • Septal perforation/deviation
    • Endometriosis

Otalgia (Ear Pain)

Local Causes:

  • Furuncle (boil) due to Staph Aureus infection
  • Foreign body in external auditory canal/impacted cerumen
  • Infection (otitis externa, acute otitis media, acute mastoiditis)
  • Trauma to tympanic membrane and canal
  • Barotrauma

Referred Causes (10 T’s + 2):

  • CN V and CN X refer to external canal, CN IX to middle ear
  • Eustachian Tube
  • TMJ (temporomandibular joint) syndrome
  • Trismus (e.g., pterygoids, quinsy)
  • Teeth – impacted
  • Tongue
  • Tonsillitis, tonsillar cancer, post tonsillectomy
  • Tic (CN IX) – glossopharyngeal neuralgia
  • Throat – cancer of larynx, vallecula, pyriform fossa
  • Trachea – foreign body, tracheitis
  • Thyroiditis
  • Geniculate herpes and Ramsey Hunt Syndrome (with/without CN VII palsy)

Secondary Causes:

  • Dental inflammation/infection (especially posterior teeth)
  • TMJ disorders
  • Trigeminal neuralgia
  • Consider cancers of the head and neck
  • Eagles syndrome – calcification of the stylohyoid ligament
  • Otorrhea, hearing loss, vertigo, aural fullness, tinnitus
  • Red flags: dysphagia, dysphonia, odynophagia, hemoptysis, weight loss, smoking, hearing loss, eye symptoms, immunosuppressed/diabetes

Tinnitus

External Ear:

  • Cerumen impaction
  • Otitis externa

Middle Ear:

  • Otosclerosis
  • Serous otitis media (most common cause in young)
  • Cholesteatoma

Inner Ear:

  • Presbycusis (most common cause in elderly)
  • Acoustic neuroma/Vestibular schwannoma
  • Meniere’s disease
  • Labyrinthitis (acoustic neuronitis)
  • Cochleitis/neuritis

Ototoxic Medications:

  • Antibiotics (e.g., aminoglycosides, vancomycin)
  • Diuretics (e.g., frusemide)
  • Aspirin or other salicylates

Non-auditory Causes:

  • Pulsatile tinnitus (vascular anomalies, glomus jugulare, hemangiomas, carotid body tumors, AVM, internal carotid artery bruits, patulous eustachian tube)
  • Clicking tinnitus (myoclonus of muscles – stapedius, tensor tympani, levator, and tensor palati, tetany)
  • Nasopharyngeal carcinoma (can cause unilateral otitis media with effusion, leading to hearing loss and tinnitus)

Sudden Onset Hearing Loss (SOHL) – Clinical Aetiology

Outer Ear (Conductive Hearing Loss):

  • Foreign body
  • Wax
  • Otitis externa
  • Other ear canal pathology (e.g., exostoses)
  • Trauma (syringing)

Middle Ear (Conductive Hearing Loss):

  • Otitis media with effusion
  • Haemotympanum
  • Ossicular chain discontinuity
  • Trauma
  • Barotrauma
  • Iatrogenic (post-operative)
  • Tympanic membrane perforation
  • Cholesteatoma

Inner Ear (Sensorineural Hearing Loss):

  • Idiopathic
  • Infective: viral/bacterial (HIV, CMV, HSV, mumps, rubella, syphilis)
  • Noise-induced
  • Trauma (temporal bone fracture)
  • Ototoxic drugs
  • Autoimmune (SLE, granulomatosis with polyangiitis, Cogan syndrome, relapsing polychondritis, ulcerative colitis)
  • Tumor (vestibular schwannoma, leukemia, myeloma)
  • Vascular (cerebrovascular disease, sickle cell disease)
  • Perilymphatic fistula
  • Barotrauma
  • Neurological (multiple sclerosis, cerebrovascular accident, migraine)
  • Other (diabetes mellitus, sarcoidosis)
  • Non-organic hearing loss

Aphthous Ulcer

Often Missed:

  • Crohn’s disease
  • Coeliac disease
  • Aspirin burn (if sucking on tabs)
  • HSV
  • EBV

Geographic Tongue

  • Associated with: psoriasis, food allergy, allergic contact dermatitis, asthma, atopic dermatitis, reactive arthritis, anemia, hormonal disturbance, emotional stress, early-stage type 1 diabetes.

Differential Diagnosis:

  • Oral candidiasis
  • Oral psoriasis (rare)
  • Oral lichen planus
  • Trauma
  • Herpes simplex
  • Systemic lupus erythematosus
  • Oral leukoplakia
  • Appearance changes over several days
  • Asymptomatic, reassure, resolves over time without treatment

Angular Cheilitis

  • Red/sore macerated corners of mouth
  • Usually due to:
    • Candida (likely in infancy, old age, diabetics, corticosteroid or antibiotic use, immunocompromised)
    • B12/iron deficiency
    • Poor-fitting dentures
    • Overgrowth of papillae due to poor oral hygiene, debility, antibiotics, steroids, tranquilizers

Hoarse Voice

General Rule:

  • Consider referral if hoarse voice persists >10 days in smokers (consider malignancy), or >3 weeks in others. Sooner referral if voice is critical for profession.

Primary Intralaryngeal Causes:

  • Acute Laryngitis (Viral/Bacterial)
  • Acute Epiglottitis
  • Croup
  • Bacterial Tracheitis
  • Chronic Laryngitis
  • Foreign Body Ingestion
  • Voice Abuse/singing (most common cause)
  • Irritants (Gastroesophageal Reflux, Alcohol Abuse, Tobacco smoke)
  • Laryngeal growths (Neoplasm, Polyp, Papillomatosis, Nodules, Reinke Edema, Traumatic Granuloma)

Secondary Intralaryngeal Causes:

  • Intrinsic Laryngeal Muscle Weakness (Hypothyroidism, Myasthenia Gravis, Bulbar palsy, Multiple Sclerosis, Age-related voice atrophy, Parkinsonism, Cerebrovascular Accident)
  • Cricoarytenoid joint Arthritis (Rheumatoid Arthritis, Gout, SLE)
  • Laryngeal Nerve Damage (surgical procedures, vagus or recurrent laryngeal nerve injury)
  • Malignancies (Thyroid, Esophageal, Lung)
  • Neuropathy (Diabetic, Viral)

Dizziness

Differential diagnosisOnset and duration of attack Provoking factorsSpecial featuresHearing LossTinnitusPhysical exam findings
LabyrinthitisFew Sec to minutes- last dayChange in the head positionTinnitusunilateralWhistlingRecent AOM
Vestibular neuronitisSeconds to minutes- last hours to daysRecent upper respiratory tract infectionImbalance, while nystagmus is horizontal or rotational, the direction of the fast component is away from the side of the lesionunilateralNone
Benign paroxysmal positional vertigoSecondsChange in the head positionPositionalnonNonePositive Dix−Hallpike
Ménière’s diseaseHours- mins-hrs precedes attackSpontaneousHearing loss and tinnitusUni/bilateral+Aural Fulness/pressureHearing assessment for sensorineural hearing loss

Exophthalmus (Proptosis)

Definition:

  • Abnormal protrusion of the eyeball
  • Exophthalmus may specifically refer to endocrinopathies or severe proptosis >18mm

Causes:

  1. Thyroid orbitopathy (most common)
  2. Infection:
    • Orbital cellulitis
    • Mucocele
    • Sinusitis
  3. Tumor:
    • Orbital lymphoma
    • Brain cancer
    • Orbital metastasis
  4. Trauma
  5. Vascular Lesions:
    • Fistula
    • Hemangioma
    • Orbital varix
    • Arteriovenous malformation (AVM)
  6. Orbital Inflammatory Syndrome
  7. Pseudo-proptosis

Vision Loss

Sudden, Painless, Unilateral Vision Loss:

  • Giant cell arteritis
  • Central or branch retinal artery occlusion
  • Nonarteritic ischemic optic neuropathy
  • Retinal detachment
  • Central or branch retinal vein occlusion
  • Vitreous hemorrhage

Nontraumatic Causes of Transient (<24h) Monocular Vision Loss:

  • Amaurosis fugax (usually minutes) – embolic or thrombotic; can occur secondary to hypoperfusion states, hyperviscosity, or vasospasm
  • Migraine (can be without headache)
  • One eye closed!

Uncommon Causes:

  • Papilledema (may be associated with visual loss lasting seconds)
  • Other causes of ischemic optic neuropathy (e.g., giant cell arteritis)
  • Impending central retinal vein occlusion (CRVO)
  • Glaucoma
  • Posterior reversible encephalopathy syndrome (PRES)
  • Large vessel occlusion or dissection (e.g., ocular ischemic syndrome, carotid occlusive disease, vertebrobasilar insufficiency, carotid or vertebral artery dissection)
  • Functional visual loss (e.g., hysteria, malingering)

Nontraumatic Causes of Acute Persistent Monocular Vision Loss:

Painless Acute Persistent Loss of Vision:

  • Central retinal artery occlusion (CRAO)
  • Central retinal vein occlusion (CRVO)
  • Retinal detachment or hemorrhage
  • Vitreous hemorrhage
  • Optic or retrobulbar neuritis
  • Internal carotid artery occlusion

Painful Acute Loss of Vision:

  • Acute glaucoma
  • Endophthalmitis
  • Uveitis
  • Keratoconus (vision can deteriorate rapidly and is associated with photophobia)

Nontraumatic Causes of Acute Binocular Loss of Vision:

Transient:

  • Migraine
  • Vertebrobasilar insufficiency (transient)

Prolonged:

  • Stroke
  • Poisons/toxic optic neuropathy (e.g., methanol, quinine, ethambutol, ergot alkaloids, salicylates)
  • Posterior reversible encephalopathy syndrome (PRES)
  • Optic or retrobulbar neuritis
  • Hysteria
  • Malingering

Post-traumatic Causes of Vision Loss (From ‘Front to Back’):

  • Lid injury
  • Orbital blow-out fracture
  • Corneal abrasion, irregularity, or laceration
  • Hyphema
  • Traumatic mydriasis
  • Traumatic iritis
  • Ruptured globe
  • Traumatic cataract
  • Lens dislocation
  • Commotio retinae
  • Retinal detachment
  • Retinal or vitreous hemorrhage
  • Intra-ocular foreign body
  • Traumatic optic neuropathy or optic nerve avulsion
  • CNS injury

Acute Renal Failure

Triggers:

  • Hypovolemia: sepsis, critical illness, circulatory shock, burns, trauma
  • Drugs: NSAIDs, PPI, antibiotics
  • Vasculitis/rheumatologic conditions: rash, arthralgia
  • Kidney stones
  • Contrast
  • Lower urinary tract symptoms (LUTS) obstruction
  • Poisonous animals
  • Heatwave

Causes:

Pre-renal:

  • Volume responsive AKI (monitor hemodynamics, challenge with volume)
  • Sepsis-induced AKI
  • Hypotension (manage aggressively)
  • Renovascular disorders

Renal:

  • Nephrotoxins: allopurinol, aminoglycosides, amphotericin, frusemide, NSAIDs, ACE inhibitors, organic solvents, contrast, sulfonamides, thiazides, herbal medicines, heavy metals, pentamidine, paraquat
  • Glomerular disease
  • Hemolytic uremic syndrome (HUS)
  • Crystal nephropathy
  • Tubulointerstitial disease
  • Rhabdomyolysis

Post-renal:

  • Obstruction at any post-renal site (tumor, clot, papillary necrosis, foreign body, post-surgical, blocked IDC)
  • Abdominal compartment syndrome

Hypothyroidism

Aetiology:

  1. Iodine Deficiency: Most common cause worldwide; uncommon in Australia
  2. Hashimoto (Autoimmune chronic lymphocytic) Thyroiditis: Most common cause in Australia
  3. Hypothyroid Stage of Any Thyroiditis: Post-viral, autoimmune
  4. Drugs:
    • Carbimazole/Propylthiouracil (PTU)
    • Lithium
    • Radioactive iodine (RAI)
    • Amiodarone
  5. Transient:
    • Subacute thyroiditis
    • Silent thyroiditis
    • Postpartum thyroiditis
    • Early postablative therapy
  6. Infiltrative Diseases:
    • Riedel’s thyroiditis
    • Scleroderma
    • Tuberculosis
    • Hemochromatosis
  7. Neonatal/Congenital:
    • Thyroid agenesis/ectopia
    • Genetic disorders affecting thyroid hormone synthesis
    • Transplacental passage of TSH receptor-blocking antibody
  8. Postablative Therapy or Surgery:
    • Radioiodine therapy
    • Thyroidectomy

Diabetes – Secondary Causes

  1. Diseases of the Exocrine Pancreas:
    • Pancreatitis
    • Trauma/pancreatectomy
    • Neoplasia
    • Cystic fibrosis
    • Hemochromatosis
  2. Endocrine Disorders:
    • Acromegaly
    • Cushing’s syndrome
    • Pheochromocytoma
    • Hyperthyroidism
  3. Drug- or Chemical-Induced:
    • Nicotinic acid
    • Glucocorticoids
    • Thyroid hormone
    • β-adrenergic agonists
  4. Infections:
    • Congenital rubella
    • Cytomegalovirus (CMV)

Predisposing Factors:

  • Pancreatic disease
  • Cushing’s disease
  • Obstructive sleep apnea
  • Medications (corticosteroids, antipsychotics)
  • Autoimmune diseases (hypothyroidism, hyperthyroidism)

Risk Factors for Suicide (SADPERSONS)

S – Sex: male > female
A – Age: adolescent & elderly
D – Depression or hopelessness
P – Previous self-harm
E – Excessive alcohol or drug abuse
R – Rationality loss
S – Separated, widowed, divorced
O – Organized or serious planned attempt (e.g., suicide note written, will changed)
N – No social supports (no close/reliable family, friends, or siblings)
S – Stated future intention to self-harm

Organic Causes of Psychosis

Neurological:

  • Epilepsy
  • Head injury
  • Cerebrovascular disease
  • Brain tumor
  • Dementia
  • Encephalitis (e.g., HSV/HIV)
  • Neurosyphilis
  • Brain abscess

Endocrine:

  • Hypo/hyperthyroidism
  • Cushing’s
  • Hyperparathyroidism
  • Addison’s disease

Metabolic:

  • Uremia
  • Sodium imbalance
  • Porphyria

Systemic Lupus Erythematosus (Lupus Psychosis)

Medications:

  • Steroids
  • L-dopa
  • Anticholinergics
  • Antihypertensives
  • Anticonvulsants
  • Methylphenidate

Drugs:

  • Cocaine
  • LSD
  • Cannabis
  • PCP
  • Amphetamines
  • Opioids

Toxins

Organic Causes of Depression

Medical Disorders:

  • Substance-induced
  • Mononucleosis (EBV)
  • Thyroid or adrenal dysfunction
  • AIDS (neurotrophic virus)
  • Medications (cardiac, antihypertensives, sedatives, hypnotics, antipsychotics, antiepileptics, antiparkinsonian, analgesics, antibacterials, antineoplastic drugs)

Neurological Disorders:

  • Parkinson’s (50-75% have depression)
  • Alzheimer’s
  • Epilepsy (especially temporal lobe epilepsy)
  • Stroke
  • Tumors

Pseudodementia:

  • Cognitive symptoms in Major Depressive Disorder (MDD) have sudden onset and diurnal variation
  • Depressed patients often say “I don’t know” whereas dementia patients try to answer
  • In MDD, recent memory is more affected than remote memory

Bipolar I or II:

  • Rule out mania-like symptoms

Other Mental Disorders:

  • Psychotic disorders, eating disorders, adjustment disorders, somatoform disorders, anxiety disorders

Bereavement and Loss:

  • Responses to significant loss (bereavement, financial ruin, natural disaster, serious medical illness, or disability)
  • Symptoms: intense sadness, rumination, insomnia, poor appetite, weight loss
  • Consider a major depressive episode in addition to normal grief

Organic Causes of Mania

Neurological:

  • Cerebrovascular accident (CVA)
  • Epilepsy
  • Brain tumor
  • Head injury
  • Multiple sclerosis (MS)

Endocrine:

  • Hyperthyroidism

Medications:

  • Steroids
  • Antidepressants
  • Mefloquine
  • Cytotoxics

Drugs:

  • Cannabis
  • Cocaine
  • Amphetamines

Toxins

Organic Causes of Anxiety

Neurological:

  • Epilepsy
  • Dementia
  • Head injury
  • Cerebrovascular accident (CVA)
  • Brain tumor
  • Multiple sclerosis (MS)
  • Parkinson’s disease

Pulmonary:

  • Chronic obstructive pulmonary disease (COPD)

Cardiac:

  • Arrhythmias
  • Congestive cardiac failure (CCF)
  • Angina
  • Mitral valve prolapse

Endocrine:

  • Hyperthyroidism

Medications:

  • Antidepressants
  • Antihypertensives
  • Flumazenil
  • Yohimbine
  • Fenfluramine

Drugs:

  • Alcohol
  • Benzodiazepines
  • Caffeine
  • Cannabis
  • Cocaine
  • LSD
  • Ecstasy (MDMA)
  • Amphetamines

ADHD and Autism

ADHD:

  • Symptoms: inattention, hyperactivity, impulsivity
  • Differential diagnosis: normal behavior, specific learning disorder, intellectual disability, emotional trauma, substance abuse

Autism (AuDHD):

  • Symptoms: social interaction difficulties, communication challenges, repetitive behaviors, restricted interests
  • Differential diagnosis: emotional disturbance, adjustment reaction, attachment disorder/PTSD, anxiety/depression, personality disorders (borderline, narcissistic)
  • Specific features: sensory sensitivities, rigidity, repetitive behaviors

Overlap:

  • In social settings, poor concentration (ADHD) may resemble inability to comprehend (autism)
  • Negativity and controlling behavior (ODD) may resemble rigidity in autism

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