Family medicine
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.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Poor oral hygiene / Periodontal disease | Bleeding gums, plaque, tongue coating, infrequent dental visits | 「有冇牙肉出血、牙石多？幾耐睇一次牙醫？」 |
| Tongue coating (dorsum bacteria) | Thick white/yellow tongue coating; mouth-breather | 「條脷面有冇厚厚嘅脷苔？」 | |
| Dietary / lifestyle | Garlic, onion, smoking, alcohol | 「有冇食煙飲酒、食多蒜頭？」 | |
| Serious Not To Miss | Nasopharyngeal carcinoma (NPC) | Epistaxis, unilateral nasal obstruction, cervical lymphadenopathy, conductive hearing loss (HK endemic) | 「有冇流鼻血？一邊鼻塞？頸有冇粒嘢？耳仔有冇聽唔清？」 |
| Oropharyngeal / oral cavity malignancy | Non-healing ulcer, dysphagia, weight loss, smoking/alcohol, betel nut | 「口入面有冇痱滋好耐唔好？有冇吞嘢困難？」 | |
| Lung abscess / advanced bronchiectasis | Copious foul-smelling sputum, fever, haemoptysis | 「有冇咳好多好臭嘅痰？有冇發燒咳血？」 | |
| Diabetic ketoacidosis | Fruity/acetone breath, polyuria, polydipsia, altered consciousness | 「有冇糖尿病？有冇成日口渴去廁所？」 | |
| Pitfalls | Chronic rhinosinusitis | Purulent nasal/post-nasal discharge, nasal obstruction, facial discomfort, headache, halitosis [1] | 「有冇鼻塞、黃鼻涕、鼻水倒流、面痛？」 |
| Tonsilloliths / chronic tonsillitis | Recurrent sore throat, white debris on tonsils, foreign body sensation | 「有冇成日喉嚨痛？扁桃腺有冇白色粒粒？」 | |
| GERD | Heartburn, acid brash, worse supine/postprandial | 「有冇胃酸倒流、食完飯或者瞓低嗰陣差啲？」 | |
| Xerostomia (dry mouth) | Medications (anticholinergics, antidepressants), Sjögren's, radiation | 「把口成日好乾？食緊咩藥？」 | |
| Masquerades | Drugs | Anticholinergics, DMARDS, some supplements → dry mouth → halitosis | 「有冇轉過藥之後開始有口臭？」 |
| Diabetes mellitus | Poorly controlled DM → periodontal disease; DKA → ketotic breath | 「有冇糖尿病？血糖控制得好唔好？」 | |
| Depression | Neglected self-care/oral hygiene, low mood, anhedonia | 「最近心情點？有冇對嘢失去興趣？」 | |
| Trying to Tell Me Something? | Halitophobia / pseudohalitosis | No objective halitosis; excessive self-consciousness; OCD traits | 「有邊個同你講過有口臭？定係你自己覺得？」 |
| Social embarrassment / relationship strain | Partner complained; avoids social situations | 「口臭有冇影響你同伴侶或者朋友嘅關係？」 | |
| Anxiety / health anxiety | Fear of cancer (esp NPC in HK context) | 「你最擔心係咩？有冇擔心係嚴重嘅病？」 |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, introduction, rapport | 「你好，我係X醫生，今日由我幫你睇症。請問點稱呼你？」「你坐得舒唔舒服？」 | Friendly opening scores interpersonal marks |
| 0:30–1:30 | Open-ended exploration of chief complaint | 「可唔可以講吓你今日嚟睇醫生最主要想傾啲咩？」「口臭嘅情況係幾時開始㗎？」「平時自己聞到定係有人同你講？」 | Lets patient tell their story; avoids premature closure |
| 1:30–2:30 | Symptom analysis + red flags | 「有冇流鼻涕或者鼻塞？」「有冇喉嚨痛或者牙肉痛、流血？」「有冇痰多或者咳血？」「體重有冇減輕？食嘢吞得順唔順？」 | Covers ENT, oral, respiratory, GI causes; red flags for malignancy |
| 2:30–3:30 | ICE + Hidden agenda | 「你自己覺得口臭係咩原因？」(Ideas)「你最擔心啲咩？」(Concerns)「你今日嚟最希望我幫到你啲咩？」(Expectations)「呢個問題有冇影響到你同人相處或者返工？」 | ICE is heavily marked; uncovers psychosocial hidden agenda |
| 3:30–4:30 | PMHx, DHx, social Hx, targeted review | 「之前有冇睇過牙醫？」「食緊咩藥？有冇藥物敏感？」「有冇食煙飲酒？」「飲食習慣點？有冇食好多蒜頭洋蔥？」「有冇糖尿病或者胃酸倒流？」 | Completes history; captures masquerades and drugs |
| 4:30–5:15 | Signpost, summarise, check understanding | 「等我同你總結吓：你話口臭已經幾個月，鼻又有少少塞，你擔心⋯⋯我有冇聽漏咗啲咩？」 | Demonstrates active listening; scores summarising marks |
| 5:15–6:00 | Brief plan, safety-net, close | 「我建議幫你檢查吓口腔同鼻，有需要嘅話再照吓。如果情況差咗或者有出血、吞嘢困難，一定要返嚟。」「仲有冇其他嘢想問？」 | Safe closing with safety-net and invitation for questions |
Uncovering the hidden agenda: The patient may present with halitosis but the real reason for attending is social embarrassment (e.g. partner/colleague commented), fear of cancer (especially NPC in HK), or underlying depression/anxiety. Always ask: 「究竟係咩令你今日決定嚟睇醫生？」("What made you decide to come today?")
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did you first notice the bad breath? | 「口臭幾時開始㗎？」 | Acute vs chronic narrows DDx | Acute → infection; Chronic → periodontal, sinusitis |
| Source | Do YOU smell it, or did someone else tell you? | 「你自己聞到定係人哋話你有口臭？」 | Self-perceived only → halitophobia/pseudohalitosis | Pseudohalitosis / psychogenic |
| Oral symptoms | Any bleeding gums, toothache, loose teeth, ulcers? | 「有冇牙肉出血、牙痛、牙鬆、痱滋？」 | #1 cause of genuine halitosis | Gingivitis, periodontitis, dental caries |
| Nasal symptoms | Any nasal blockage, runny nose, post-nasal drip, loss of smell? | 「有冇鼻塞、流鼻涕、鼻水倒流、聞唔到嘢？」 | Chronic rhinosinusitis is a key cause [1] | CRS, nasal polyps |
| Sinus/facial pain | Any facial pain or headache? | 「有冇面痛或者頭痛？」 | CRS features: facial discomfort, headache [1] | Chronic rhinosinusitis |
| Throat/ENT | Any sore throat, tonsil stones, ear pain? | 「有冇喉嚨痛、耳仔痛？」 | Tonsilloliths / pharyngeal infection | Chronic tonsillitis, tonsilloliths |
| Respiratory | Any chronic cough, copious/foul sputum, haemoptysis? | 「有冇成日咳？痰多唔多？痰臭唔臭？有冇咳血？」 | Foul sputum + halitosis → bronchiectasis [2] | Bronchiectasis, lung abscess |
| GI/GERD | Any heartburn, acid reflux, burping? | 「有冇胃酸倒流、火燒心、成日噯氣？」 | GERD is a common pitfall cause | GERD |
| Dysphagia / weight loss | Any difficulty swallowing or weight loss? | 「吞嘢有冇困難？體重有冇輕咗？」 | Red flag for oropharyngeal/oesophageal malignancy, NPC | Malignancy |
| Epistaxis / blood-stained discharge | Any nosebleeds or blood in nasal discharge? | 「有冇流鼻血或者鼻涕有血絲？」 | Red flag for NPC (high yield in HK) [1] | NPC |
| Neck lump | Any lumps in the neck? | 「頸有冇摸到粒嘢？」 | Cervical lymphadenopathy → NPC | NPC, lymphoma |
| Dry mouth | Is your mouth often dry? | 「把口成日好乾？」 | Xerostomia reduces saliva → halitosis | Sjögren's, medications, mouth-breathing |
| Drug history | What medications are you taking? | 「而家食緊咩藥？」 | Many drugs cause xerostomia or odour | Anticholinergics, antidepressants, antihistamines |
| Smoking/alcohol | Do you smoke or drink? | 「有冇食煙飲酒？」 | Direct cause; also risk factor for oral/pharyngeal cancer | Smoking-related halitosis, malignancy risk |
| Diet | Do you eat a lot of garlic, onion, spicy food? | 「平時食唔食多蒜頭、洋蔥、辛辣嘢？」 | Dietary cause is common and benign | Dietary halitosis |
| Diabetes | Any history of diabetes? Excessive thirst/urination? | 「有冇糖尿病？有冇特別口渴、去多咗廁所？」 | Diabetic ketoacidosis → fruity breath; DM → periodontal disease | DKA, poorly controlled DM |
| Dental visits | When did you last see a dentist? | 「最近幾時睇過牙醫？」 | Poor dental hygiene is #1 cause | Periodontal disease, caries |
| Social/functional | Does this affect your social life, work, or relationships? | 「口臭有冇影響你社交、返工、或者同伴侶相處？」 | Psychosocial impact → biopsychosocial problem | Social embarrassment, anxiety, relationship strain |
| Psych screen | Have you been feeling stressed, anxious, or low in mood? | 「最近壓力大唔大？有冇唔開心或者緊張？」 | Hidden agenda: anxiety/depression; halitophobia | Depression, anxiety, OCD-spectrum |
Case Report Form Answer Builder
- CC: Halitosis for [duration]
- HPI key points to capture:
- Duration, onset (gradual vs sudden), constant vs intermittent
- Who noticed it (self vs others) — critical to distinguish genuine vs pseudohalitosis
- Associated oral symptoms (gum bleeding, toothache, ulcers, tongue coating)
- Associated nasal symptoms (obstruction, purulent discharge, post-nasal drip, facial pain)
- Associated GI symptoms (acid reflux, heartburn)
- Associated respiratory symptoms (productive cough, foul sputum)
- Red flags: weight loss, dysphagia, epistaxis, neck lump, non-healing ulcer
- Dental hygiene habits, last dental visit
- Smoking, alcohol, diet
- Medications causing xerostomia
- Psychosocial impact
- Likely RFC examples:
- "Partner/colleague said I have bad breath and I am embarrassed"
- "I am worried the bad breath means something serious (cancer)"
- "The bad breath is affecting my social/work life"
- Best single answer phrasing: "Social embarrassment due to persistent halitosis, worried about underlying serious cause"
| Component | Likely Content | Exact Wording Example |
|---|---|---|
| Ideas | Patient thinks it may be from stomach, teeth, or something serious | "Patient thinks halitosis is caused by stomach problem / poor digestion" |
| Concerns | Fear of cancer (NPC/oral ca) or social rejection | "Patient is worried the bad breath may indicate cancer" |
| Expectations | Wants investigation, referral to specialist, or quick fix | "Patient hopes for investigation and treatment to eliminate the smell" |
- Periodontal disease / poor oral hygiene — this is the #1 cause of halitosis (~85–90% of cases are intra-oral)
- Minimum supporting evidence: history of infrequent dental visits, bleeding gums, visible plaque/calculus, tongue coating, no red flags for sinister pathology
If the stem gives nasal symptoms prominently → consider Chronic rhinosinusitis [1]
| DDx | Key Discriminator |
|---|---|
| 1. Chronic rhinosinusitis | Nasal obstruction + purulent nasal/post-nasal discharge + facial pain/headache + halitosis [1] |
| 2. GERD | Heartburn, acid brash, worse when supine, postprandial |
| 3. Tonsilloliths / chronic tonsillitis | Recurrent sore throat, white concretions on tonsils, foreign body sensation in throat |
(Adjust based on stem: if respiratory symptoms → substitute bronchiectasis; if weight loss/epistaxis in HK → substitute NPC)
| Domain | Problem |
|---|---|
| Biological | Periodontal disease / gingivitis requiring dental referral and treatment |
| Psychological | Anxiety and loss of self-confidence due to halitosis; possible health anxiety (fear of cancer) |
| Social | Social embarrassment leading to avoidance of close interaction; impact on intimate/work relationships |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Periodontal disease (most likely) | Inflamed, erythematous, swollen gingiva ± bleeding on probing; visible plaque/calculus; thick tongue coating | Inspect oral cavity with tongue depressor and pen torch; ask patient to open mouth and stick out tongue | Direct evidence of intra-oral bacterial source of malodour |
| Chronic rhinosinusitis | Purulent discharge in nasal cavity / post-nasal drip visible on posterior pharynx | Anterior rhinoscopy; inspect posterior pharynx with tongue depressor | Purulent nasal discharge is a hallmark feature of CRS [1] |
| GERD | Dental erosion of lingual surfaces of upper teeth; pharyngeal erythema | Inspect teeth (especially upper inner surfaces); inspect posterior pharynx | Acid damage to enamel indicates chronic reflux |
| Tonsilloliths | White/yellow concretions in tonsillar crypts | Inspect both tonsils with tongue depressor and good light | Direct visualization of the malodourous calcified bacterial debris |
| NPC | Cervical lymphadenopathy (upper deep cervical, posterior triangle); middle ear effusion | Palpate cervical lymph node stations bilaterally; otoscopy | Posterior cervical LN + unilateral serous OME in an adult in HK is NPC until proven otherwise |
| Bronchiectasis | Finger clubbing + coarse inspiratory crackles (lower zones) | Inspect nail beds; auscultate lung bases | Clubbing + halitosis + copious foul sputum = bronchiectasis [2] |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to ask WHO noticed the halitosis — if only self-perceived with no objective confirmation, consider pseudohalitosis / halitophobia. This changes diagnosis entirely.
- Jumping to GI causes — students commonly attribute halitosis to "stomach problems." In reality, ~85-90% of genuine halitosis is intra-oral (periodontal disease, tongue coating). GI causes (GERD, Zenker's diverticulum) are uncommon.
- Missing NPC in HK context — always screen for epistaxis, unilateral nasal obstruction, neck lump, and hearing loss. NPC is endemic in Southern China / HK.
- Not exploring ICE — the hidden agenda is often social embarrassment or cancer fear. Marks are lost if ICE is blank or generic.
- Not asking about dental visits — this is the most actionable history item and the most common management step (refer to dentist).
- Ignoring medications — many drugs cause xerostomia → halitosis. Always ask DHx.
| Red Flag | Think Of | Action |
|---|---|---|
| Unilateral epistaxis + nasal obstruction + cervical LN | NPC | Urgent ENT referral + nasopharyngoscopy |
| Non-healing oral ulcer > 3 weeks | Oral cavity malignancy | Urgent ENT/OMFS referral |
| Progressive dysphagia + weight loss | Oesophageal/pharyngeal Ca | Urgent endoscopy/imaging |
| Copious foul sputum + haemoptysis + fever | Lung abscess | CXR, CT, urgent respiratory referral |
| Fruity/acetone breath + polyuria + confusion | DKA | Emergency — check glucose, ABG, admit |
"I'd like to examine your mouth and nose today. The most common cause of bad breath is from the mouth itself — I'd recommend seeing a dentist for a thorough check. In the meantime, good tongue brushing and staying hydrated can help. If you notice any nosebleeds, blood in your spit, difficulty swallowing, a neck lump, or weight loss, please come back urgently."
High Yield Summary
What to ASK: Who noticed it (self vs others)? Oral symptoms (gum bleeding, dental visits)? Nasal symptoms (obstruction, purulent discharge, facial pain)? Red flags (epistaxis, neck lump, dysphagia, weight loss)? ICE — especially cancer fear and social embarrassment.
What to WRITE: CC = halitosis × duration. Most likely Dx = periodontal disease / poor oral hygiene. DDx = chronic rhinosinusitis, GERD, tonsilloliths. Biopsychosocial = gingivitis (bio), anxiety/cancer fear (psych), social avoidance (social). Physical sign = inflamed gingiva / tongue coating on oral examination.
What NOT to MISS: NPC screening in any HK patient with halitosis + nasal symptoms. Pseudohalitosis if only self-perceived. Medications causing dry mouth. Always ask about last dental visit.
Active Recall - Family Medicine Clinical Test
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.
Hallucinations
Hallucinations are false sensory perceptions occurring without an external stimulus, experienced as real by the individual, and can involve any sensory modality including auditory, visual, tactile, olfactory, or gustatory.