Family medicine
Hair Loss
Hair loss, or alopecia, is the partial or complete absence of hair from areas where it normally grows, resulting from disrupted hair growth cycles due to genetic, hormonal, autoimmune, nutritional, or other pathological factors.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Androgenetic alopecia (AGA) | Gradual thinning at crown/temples ± FH; non-scarring | 「頭頂定係額角位薄咗？爸爸媽媽有冇甩頭髮？」 |
| Telogen effluvium | Diffuse shedding 2–4 months post-trigger (stress, illness, post-partum, crash diet) | 「兩三個月前有冇大病、生BB、減肥或者好大壓力？」 | |
| Serious Not To Miss | SLE / Discoid lupus | Scarring patches, malar rash, photosensitivity, joint pain, oral ulcers | 「面有冇蝴蝶形紅疹？曬太陽有冇敏感？」 |
| Scarring alopecia (lichen planopilaris) | Permanent loss, perifollicular erythema/scale, scalp tenderness, loss of follicular ostia | Exam: look for shiny smooth scalp with absent follicular openings | |
| Secondary syphilis | Moth-eaten alopecia + genital ulcer Hx, rash | 「有冇性接觸史？身有冇出過疹？」 | |
| Pitfalls | Alopecia areata | Well-demarcated round patches, exclamation-mark hairs, nail pitting | 「甩嘅位置係唔係圓圓一撻？周圍有冇短短嘅斷髮？」 |
| Tinea capitis | Scaling, broken hairs, +/− kerion; children/contact Hx; KOH positive | 「頭皮有冇脫皮？有冇接觸動物？」 | |
| Trichotillomania | Irregular patches with broken hairs of different lengths; often in children/adolescents/OCD | 「有冇自己拔頭髮嘅習慣？」 | |
| Masquerades | Hypothyroidism | Diffuse thinning + fatigue, cold intolerance, weight gain, constipation, dry skin | 「有冇怕凍、便秘、皮膚乾？」 |
| Iron deficiency anaemia | Diffuse thinning + pallor, fatigue, menorrhagia, dietary deficiency | Exam: pallor of conjunctivae; 「月經量多唔多？有冇食素？」 | |
| Drug-induced alopecia | Temporal relation to new medication (isotretinoin, anticoagulants, OCP, chemotherapy) | 「近排有冇食新藥？」 | |
| Trying to Tell Me Something? | Psychosocial stress / body image distress / depression | Significant stress, anxiety about appearance, social withdrawal, low mood | 「你最擔心啲咩？甩頭髮有冇影響你嘅心情同社交？」 |
Minute-by-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport | 「你好，我係X醫生，請坐。今日有咩可以幫到你呀？」(Hello, I'm Dr X, please sit. How can I help you today?) | Greeting + open question scores interpersonal marks |
| 0:30–1:30 | HPI: Onset, duration, pattern, severity of hair loss | 「甩頭髮嘅情況幾時開始㗎？係慢慢甩多咗定係突然間甩好多？有冇一撻撻咁甩？定係成頭都薄咗？」 | Characterise the alopecia pattern — focal vs diffuse, acute vs chronic |
| 1:30–2:30 | Associated symptoms & red flags | 「頭皮有冇痕、痛、紅、或者出屑？身體其他地方毛髮有冇少咗？有冇皮疹、關節痛、口腔潰瘍？近排有冇好攰、怕凍、便秘、體重變化？」 | Screen thyroid, SLE, iron deficiency, scarring alopecia |
| 2:30–3:30 | PMH, drug Hx, family Hx, menstrual/OG Hx | 「你有冇長期病？食緊咩藥？有冇食新嘅藥或者保健品？屋企人有冇甩頭髮嘅問題？月經正唔正常？有冇可能懷孕？」 | Drug-induced alopecia (e.g. isotretinoin, chemotherapy), PCOS, post-partum, family pattern |
| 3:30–4:30 | Social Hx, stress, occupation, functional impact | 「你做咩工作？最近壓力大唔大？瞓得好唔好？食嘢有冇特別節食？甩頭髮有冇影響到你日常生活或者心情？」 | Telogen effluvium trigger (stress, crash diet); psychological impact is marks-bearing |
| 4:30–5:15 | ICE (Ideas, Concerns, Expectations) | 「你自己覺得甩頭髮嘅原因係咩呀？最擔心啲咩？（停一停）你今日嚟最想我幫到你啲咩？」 | ICE is directly tested on the case report. Pause after each question. |
| 5:15–5:45 | Summarise & check understanding | 「等我總結吓：你話…嘅情況已經X個月，你最擔心…，最想…。我有冇理解錯？」 | Demonstrates active listening, scores summarising marks |
| 5:45–6:00 | Close safely | 「我想之後幫你做個簡單檢查，同埋抽血驗吓甲狀腺同鐵質。如果甩頭髮突然嚴重咗，或者頭皮出現紅腫疤痕，記得盡快返嚟覆診。」 | Safety net + signposting next steps |
Uncovering the hidden agenda: The patient may present with "hair loss" but the real reason for consultation could be fear of cancer/SLE, cosmetic distress, relationship impact, or a recent stressor (e.g. post-partum, bereavement, work stress). Ask explicitly: 「你今日點解決定嚟睇醫生？係咪有啲特別嘢令你擔心？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Pattern | Is the hair loss patchy or all over? | 「甩頭髮係一撻撻定係成頭都薄咗？」 | Focal → alopecia areata, tinea capitis, scarring; Diffuse → telogen effluvium, AGA, thyroid | Alopecia areata vs androgenetic vs diffuse |
| Onset / Duration | When did it start? Sudden or gradual? | 「幾時開始？係突然定係慢慢㗎？」 | Acute onset → alopecia areata, telogen effluvium; Gradual → AGA, thyroid | Telogen effluvium if 2–4 months after trigger |
| Scalp symptoms | Any itch, pain, redness, scaling, scarring? | 「頭皮有冇痕、痛、紅、脫皮、或者疤痕？」 | Scarring alopecia (lichen planopilaris, discoid lupus) is irreversible — must not miss | Scarring alopecia if pain + scarring |
| Trigger event | Any recent illness, surgery, crash diet, childbirth, or major stress 2–4 months ago? | 「兩三個月前有冇大病、做手術、生BB、減肥或者好大壓力？」 | Classic telogen effluvium trigger window | Telogen effluvium |
| Thyroid symptoms | Tired? Cold intolerance? Weight change? Constipation? | 「有冇覺得好攰、怕凍、肥咗、便秘？」 | Hypothyroidism causes diffuse hair loss [1] | Hypothyroidism |
| Iron/anaemia | Heavy periods? Dizziness? Pallor? Dietary restriction? | 「月經量多唔多？有冇頭暈、面青？有冇食素或者節食？」 | Iron deficiency — common and treatable masquerade | Iron deficiency anaemia |
| SLE screen | Facial rash? Photosensitivity? Joint pain? Mouth ulcers? | 「面有冇紅疹？曬太陽有冇敏感？關節痛？口腔潰瘍？」 | SLE can present with hair loss, oral ulcers, rashes [2] | SLE / discoid lupus |
| Drug history | Any new medications? Isotretinoin, OCP, chemotherapy, anticoagulants, antithyroid drugs? | 「近排有冇食新藥？例如暗瘡藥、避孕藥、薄血藥？」 | Isotretinoin — hair loss reversible, usually only in high dose [3] | Drug-induced alopecia |
| Family history | Anyone in family with hair loss or autoimmune disease? | 「屋企人有冇甩頭髮或者免疫系統病？」 | AGA has strong genetic component; alopecia areata clusters in families | Androgenetic alopecia, alopecia areata |
| Menstrual / OG | Period regular? Post-partum? Acne/hirsutism? | 「月經準唔準？有冇剛生完BB？面同身有冇多咗毛或暗瘡？」 | PCOS (virilisation: hirsutism, temporal balding, acne [4]); post-partum telogen effluvium | PCOS, post-partum TE |
| Psychological impact | How does hair loss affect your mood/daily life? | 「甩頭髮有冇影響你心情、社交或者自信？」 | Psychological problem is tested in biopsychosocial; may reveal hidden depression/anxiety | Body image distress, depression |
| Health-seeking | Have you tried any treatments? Why come today? | 「你有冇試過咩方法？今日點解決定嚟睇？」 | Uncovers expectations and hidden agenda | Concern about specific disease |
Case Report Form Answer Builder
- CC: Hair loss for [duration]
- HPI points to capture:
- Pattern: diffuse vs focal; location (crown, temples, patches)
- Duration and onset (acute vs gradual)
- Associated scalp symptoms (itch, pain, scaling, scarring)
- Trigger 2–4 months prior (illness, stress, post-partum, diet, surgery)
- Systemic symptoms: thyroid (fatigue, cold intolerance), SLE (rash, joints), anaemia (pallor, menorrhagia)
- Drug history, menstrual/OG history
- Family history of hair loss / autoimmune disease
- Psychological and social impact
- Likely RFC examples:
- "Worried that hair loss might indicate a serious disease (e.g. cancer, lupus)"
- "Cosmetic concern and distress about appearance"
- "Wants to know the cause and treatment options"
- Best phrasing: Write the patient's own words — e.g. "Patient is concerned about increasing hair loss affecting her appearance and worried it may be a sign of serious illness."
| Component | Likely Content | Example Wording |
|---|---|---|
| Ideas | "I think it might be stress" / "Maybe hormonal" / "Worried it's lupus" | "Patient thinks hair loss is due to recent work stress" |
| Concerns | Fear of going bald, fear of serious disease, embarrassment | "Patient is worried she will become completely bald and feels embarrassed at work" |
| Expectations | Wants blood tests, wants medication, wants referral to dermatologist | "Patient hopes to have blood tests done and receive treatment to stop hair loss" |
- For a young woman with diffuse thinning + stressor: Telogen effluvium
- For gradual thinning at crown/temples + FH: Androgenetic alopecia (female/male pattern)
- For well-circumscribed patches: Alopecia areata
- Minimum supporting evidence: Pattern of loss + timeline + presence/absence of trigger + scalp examination findings
| DDx | One Key Discriminator |
|---|---|
| Androgenetic alopecia | Gradual bitemporal/vertex thinning, positive FH, no scalp inflammation |
| Alopecia areata | Well-demarcated smooth round patches, exclamation-mark hairs, may have nail pitting |
| Hypothyroidism | Diffuse thinning + fatigue, cold intolerance, weight gain, dry skin, raised TSH |
(Adjust depending on the stem — if patches: think alopecia areata, tinea capitis, discoid lupus as DDx)
| Domain | Problem |
|---|---|
| Biological | Underlying cause of hair loss (e.g. iron deficiency, thyroid dysfunction) requiring investigation and treatment |
| Psychological | Anxiety and low self-esteem related to hair loss / body image distress / possible depression |
| Social | Impact on social functioning, work confidence, or interpersonal relationships |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Telogen effluvium | Positive hair-pull test (>6 hairs per pull, diffuse) | Gently pull ~40–60 hairs between thumb and fingers from different scalp areas | Indicates active shedding in telogen phase; diffuse positive pull = telogen effluvium |
| Androgenetic alopecia | Widened central part / reduced hair density at crown with preserved frontal hairline (Ludwig pattern in females) | Inspect crown and part the hair centrally; compare density at crown vs occiput | Patterned distribution with miniaturised hairs is pathognomonic of AGA |
| Alopecia areata | Well-demarcated smooth patch with exclamation-mark hairs (short broken hairs tapering at base) at periphery | Inspect patch border closely; look for short tapered hairs 3–4 mm long | Exclamation-mark hairs are pathognomonic of alopecia areata |
| Hypothyroidism | Dry, coarse skin; delayed relaxation of ankle jerks; periorbital puffiness; bradycardia | Check skin texture, elicit ankle jerk and observe slow relaxation phase | Consistent with hypothyroidism as cause of diffuse hair loss [1] |
| SLE / Discoid lupus | Malar (butterfly) rash / discoid lesions with scarring on scalp | Inspect face for erythematous rash sparing nasolabial folds; inspect scalp for atrophic scarred patches | Scarring alopecia + malar rash strongly supports lupus [2] |
| Tinea capitis | Broken hairs with scaling patch ± black dots; positive KOH microscopy of scalp scraping | Scrape scale from margin of patch for KOH prep | KOH-positive hyphae confirm dermatophyte infection |
| Iron deficiency | Conjunctival pallor; koilonychia (spoon-shaped nails) | Pull down lower eyelid to inspect conjunctival colour; inspect nails | Pallor + koilonychia are classic signs of iron deficiency causing hair loss |
| Trichotillomania | Irregular patch of hair loss with hairs of different lengths, no scalp inflammation | Inspect: irregularly shaped area, no smooth surface, broken hairs at different lengths | No physical sign is reliable in brief FM station — history of hair-pulling behaviour is the key clue |
Top Traps That Lose Marks
- Forgetting to ask about scarring — Scarring alopecia (discoid lupus, lichen planopilaris) causes irreversible loss. Examine the scalp for absent follicular ostia and refer urgently to dermatology.
- Not asking menstrual/OG history — Post-partum telogen effluvium and PCOS are high-yield FM causes; omitting this loses easy marks.
- Missing drug-induced alopecia — Always ask about isotretinoin [3], anticoagulants, OCP, antithyroid drugs, chemotherapy, valproate.
- Confusing alopecia areata with tinea capitis — Areata is smooth and non-scaly; tinea has scale + broken hairs + possible kerion. Ask about animal contact.
- Forgetting ICE — Marks are heavily weighted on ICE. The patient likely has a specific fear (e.g. cancer, autoimmune) — draw it out with a pause after asking.
- Not addressing psychological impact — Hair loss causes significant body image distress. This is a required biopsychosocial domain.
Must-not-miss red flags — Refer urgently if:
- Scarring alopecia (loss of follicular ostia, atrophic patches) → irreversible if untreated → urgent dermatology referral
- Signs of SLE (malar rash, joint pain, oral ulcers, cytopaenia) → urgent rheumatology/medicine workup
- Rapidly progressive total alopecia (alopecia totalis/universalis) → dermatology referral
- Suspicion of secondary syphilis (moth-eaten alopecia, rash, sexual risk) → RPR/VDRL
Shortest safe management / safety-net line: 「我會幫你安排驗血（甲狀腺、鐵質、血常規），如果頭皮有疤痕或者甩頭髮突然惡化，要盡快返嚟或者轉介皮膚科。」
High Yield Summary
What to ASK: Pattern (focal vs diffuse), onset, scalp symptoms (scarring?), trigger 2–4 months ago, thyroid symptoms, menstrual history, drug history, family history, psychological impact, ICE.
What to WRITE on the Case Report Form:
- CC: Hair loss × [duration], [pattern]
- RFC: Patient's specific fear or expectation (not just "hair loss")
- ICE: Must include all three with patient's own words
- Most likely Dx: Telogen effluvium (if trigger) or AGA (if gradual + FH) or Alopecia areata (if patches)
- DDx: Choose 3 from AGA, telogen effluvium, alopecia areata, hypothyroidism, iron deficiency, drug-induced
- Biopsychosocial: Biological cause + psychological distress + social/functional impact
- Physical sign: Hair-pull test (TE), patterned thinning (AGA), exclamation-mark hairs (AA), scalp scarring (discoid lupus)
What NOT to MISS: Scarring alopecia (irreversible), SLE, hypothyroidism, drug-induced, post-partum, iron deficiency. Always ask ICE — it is directly examined.
Active Recall - Family Medicine Clinical Test
[1] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf — Endocrine causes of short stature (hypothyroidism clinical features including hair loss) [2] Senior notes: Block A - Nephrology Interactive Tutorial.pdf — Lupus nephritis workup (hair loss, oral ulcers, rashes as autoimmune screen) [3] Senior notes: Block A - I have an itchy rash (eczema, urticaria, tinea infection and psoriasis).pdf — Isotretinoin side effects (hair loss reversible, usually only in high dose) [4] Senior notes: Maksim Medicine Notes.pdf — Hyperandrogenism (virilisation: hirsutism, temporal balding, acne)
Haemoptysis
Haemoptysis is the coughing up of blood or blood-stained sputum originating from the lower respiratory tract.
Halitosis
Halitosis is an unpleasant oral malodor most commonly caused by bacterial degradation of sulfur-containing substrates in the oral cavity, particularly on the tongue dorsum and in periodontal pockets.