General Malaise
General malaise is a nonspecific symptom of overall bodily discomfort, weakness, or feeling of being unwell that often accompanies the onset of various acute or chronic illnesses.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Viral URTI / post-viral fatigue | Self-limiting; recent coryza, sore throat [9] | 「最近有冇傷風感冒？喉嚨痛？」 | ~30% |
| Depression / anxiety | Low mood ≥ 2 wks, anhedonia, sleep disturbance, guilt [4] | 「你有冇覺得做咩都冇意思？心情低落有幾耐？」 | ~25% | |
| Iron deficiency anaemia | Fatigue, pallor, menorrhagia or poor diet [10] | Conjunctival pallor; 「月經量多唔多？有冇揀飲擇食？」 | ~15% | |
| Serious Not To Miss | Malignancy (lymphoma, leukaemia, solid organ) | Unexplained weight loss, night sweats, lymphadenopathy [5] | 「有冇摸到頸、腋下或者𨳊罅有粒嘢腫大咗？」 | ~2% |
| Chronic kidney disease / uraemia | Nausea, pruritus, café-au-lait skin, oedema [3] | 「有冇周身痕？有冇腳腫？面色偏黃啡？」 | ~2% | |
| Tuberculosis | Chronic cough, night sweats, weight loss, contact history | 「有冇咳超過兩個星期？有冇接觸過肺癆病人？」 | ~1% | |
| Acute hepatitis / liver failure | Jaundice, RUQ pain, anorexia, dark urine [6] | 「眼白有冇變黃？小便有冇好似茶色？」 | < 1% | |
| Pitfalls | Hypothyroidism | Weight gain, constipation, cold intolerance, dry skin | 「有冇怕凍、便秘、皮膚好乾？」 | ~5% |
| Infectious mononucleosis (EBV) | Young adult, sore throat, posterior cervical LN, splenomegaly [11] | 「喉嚨痛咗幾耐？頸後有冇淋巴腫？」 | ~3% | |
| Electrolyte disturbance (hypoNa, hyperK, hypercalcaemia) | Malaise, lethargy, confusion — non-specific symptoms of electrolyte disorders [12] | 「有冇嘔？頭痛？神志有冇唔清醒？」 | ~2% | |
| Masquerades | Diabetes mellitus | Polyuria, polydipsia, blurred vision | 「有冇成日口渴、去廁所？」 | ~5% |
| Drugs (side effects / TCM) | Temporal correlation with new medication [6] | 「最近有冇開始食新藥或者中藥？」 | ~5% | |
| Anaemia of chronic disease | Known chronic illness + fatigue + normocytic anaemia [10] | 「你嘅長期病最近有冇差咗？」 | ~3% | |
| Trying to Tell Me Something? | Psychosocial stress / burnout | Work/family stress, recent life event, insomnia | 「最近有冇特別唔開心嘅事？工作壓力大唔大？」 | ~20% |
| Health anxiety / cancer fear | Specific fear driving attendance | 「你最擔心呢個情況係唔係某個病？」 | ~10% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, confirm identity | 「你好，我姓X，係今日嘅醫生。請問你點稱呼？」(Hello, I'm Dr X. How should I address you?) | Rapport building; interpersonal marks start here |
| 0:30–1:30 | Open-ended HPI: let patient describe malaise | 「你今日嚟睇醫生，最主要係咩問題呀？可以講多啲俾我聽。」(What's your main problem today? Tell me more.) 「呢個情況幾時開始㗎？之後點樣變化？」 | Chief complaint + timeline; lets hidden agenda surface naturally |
| 1:30–3:00 | Focused symptom analysis + red flags + targeted systems | 「有冇發燒、出冷汗、體重有冇輕咗？」「有冇覺得氣喘、心跳快？」「有冇痛嘅地方？有冇瘀傷流牙血？」 See Must-Ask table below | Covers biological DDx; red flags score heavily |
| 3:00–3:30 | PMH / DHx / Allergy / FHx / Social Hx | 「你有冇長期病？食緊咩藥？有冇食中藥或者補品？有冇藥物敏感？屋企人有冇類似嘅情況？」「你做咩工作？有冇食煙飲酒？」 | Drug history a key masquerade; social Hx for biopsychosocial |
| 3:30–4:30 | ICE (Ideas, Concerns, Expectations) | 「你自己覺得係咩原因？」(Ideas)「你最擔心係咩？」(Concerns)「你今日嚟最希望醫生幫到你啲咩？」(Expectations) | Direct marks on Case Report Form Q3 |
| 4:30–5:00 | Uncover hidden agenda / functional impact | 「呢個情況有冇影響到你返工或者日常生活？」「有冇啲嘢令你最近壓力好大、瞓唔好？」 | "Why today?" — often psychosocial; scores hidden-agenda marks |
| 5:00–5:30 | Summarise back and check understanding | 「等我總結一下你嘅情況…我理解得啱唔啱？」 | Signposting + summarising = interpersonal marks |
| 5:30–6:00 | Explain plan, safety-net, close warmly | 「我建議幫你驗吓血，了解清楚原因。如果之後出現發高燒、嘔血、或者突然好攰企唔穩，就即刻去急症室。」「多謝你嘅信任，有問題隨時搵我哋。」 | Safe closure; safety-net phrase scores exam marks |
How to uncover the hidden agenda: "General malaise" is vague — patients often attend because of a deeper worry (cancer fear, work stress, relationship issue, recent bereavement). After exploring biological symptoms, always ask 「其實你今日嚟睇，最令你擔心嘅係咩嚟㗎？」 — this single question frequently reveals the RFC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset / Duration | When did you start feeling unwell? Sudden or gradual? | 「幾時開始覺得唔舒服？係突然定慢慢嚟？」 | Acute → infection/metabolic; chronic → anaemia/malignancy/depression | Infection, thyroid, depression |
| Associated fever | Any fever, night sweats, chills? | 「有冇發燒、出夜汗、打冷震？」 | Constitutional symptoms are red flags for malignancy, TB, HIV [1] | Lymphoma, TB, HIV, endocarditis |
| Weight change | Any weight loss or gain? How much? | 「體重有冇輕咗或者重咗？大概輕咗幾多？」 | Unintentional weight loss > 5% in 6 mo = red flag [2] | Malignancy, thyrotoxicosis, DM, depression |
| Appetite | How is your appetite? | 「胃口點呀？有冇食少咗嘢？」 | Anorexia + malaise → uraemia, hepatitis, malignancy, depression [3] | CKD, liver disease, depression |
| Fatigue character | Tired all day or worse at certain times? | 「成日都攰定係朝早先攰？做完嘢之後攰啲？」 | Morning fatigue + low mood → depression; exertional → anaemia/cardiac | Depression vs anaemia vs cardiac |
| Mood / Sleep / Interest | How is your mood? Sleep? Enjoying things? | 「心情點呀？瞓得好唔好？平時鍾意做嘅嘢仲有冇興趣？」 | Depression is a top masquerade for general malaise [4] | Depression, anxiety, adjustment disorder |
| SOB / Palpitations | Any breathlessness or fast heartbeat? | 「有冇覺得氣喘、或者心跳得好快？」 | Anaemia, heart failure, thyrotoxicosis | Anaemia, HF, thyrotoxicosis |
| Bleeding | Any unusual bleeding — gums, heavy periods, black stool? | 「有冇流牙血、經期多咗、定屙黑色大便？」 | Occult blood loss → IDA; marrow failure → leukaemia [5] | IDA, leukaemia, GI malignancy |
| Thyroid symptoms | Heat/cold intolerance, tremor, bowel change? | 「有冇怕熱、怕凍、手震、便秘或者肚瀉？」 | Thyroid disease is a classic masquerade | Hypothyroidism, hyperthyroidism |
| Polyuria / Polydipsia | Passing lots of urine? Very thirsty? | 「有冇成日去廁所、好口渴？」 | New DM or hypercalcaemia | DM, hypercalcaemia, CKD |
| Joint / Muscle pain | Any joint pain, muscle weakness? | 「有冇關節痛、肌肉冇力？」 | Connective tissue disease, polymyalgia rheumatica | SLE, PMR, viral myalgia |
| Drug Hx (including TCM) | Any medications, supplements, herbal medicine? | 「有冇食西藥、中藥、保健品？包括中成藥、涼茶都算。」 | Drugs are a key masquerade; TCM hepatotoxicity must be asked [6] | Drug side effects, hepatotoxicity |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Safety | — |
| PMHx | Any chronic illnesses — DM, HT, hepatitis? | 「有冇長期病，例如糖尿、高血壓、乙型肝炎？」 | Known disease flare/complication | CKD, liver failure, DM complications |
| FHx | Family members with similar symptoms or cancers? | 「屋企人有冇類似嘅問題？有冇人有癌症或者血液病？」 | Inherited anaemia, familial cancers | Thalassaemia, familial malignancy |
| Social Hx | Smoking, alcohol, occupation, stress? | 「有冇食煙飲酒？做咩工作？最近壓力大唔大？」 | Alcohol → liver; stress → depression; occupation → exposure | Alcoholic liver disease, depression |
| Travel / Contacts | Recent travel? Sick contacts? | 「最近有冇去過旅行？身邊有冇人病？」 | Fever after travelling — malaria, dengue, typhoid [7] | Tropical infections |
| Sexual Hx (if relevant) | Any new partners? Unprotected sex? | 「有冇新伴侶？有冇冇用安全套？」 | HIV seroconversion can present as malaise [8] | Acute HIV, STIs |
| Functional impact | Can you still work/look after yourself? | 「仲做唔做到嘢？自己照顧到自己嗎？」 | Grades severity; social problem for CRF | — |
Case Report Form Answer Builder
- Chief complaint: "General malaise for ___ weeks/months"
- HPI must capture: onset, duration, progression, associated constitutional symptoms (fever, night sweats, weight loss, appetite), associated system symptoms (SOB, palpitations, bleeding, polyuria, joint pain, mood), aggravating/relieving factors, functional impact, medications (including TCM), relevant PMHx
- Examples: "Concerned about persistent tiredness affecting work"; "Worried the malaise could indicate a serious illness (e.g., cancer)"; "Requested blood tests to find a cause"
- How to phrase: State the patient's perspective — why today? Use the patient's own words if possible.
| Likely Examples | Exact Wording | |
|---|---|---|
| Ideas | "I think I might be anaemic" / "Maybe I'm too stressed" / "I read online it could be cancer" | "Patient thinks the malaise may be due to ___ (anaemia / stress / serious illness)" |
| Concerns | Fear of cancer, fear of losing job, worry about burdening family | "Patient is worried that the malaise may indicate cancer / a serious underlying condition" |
| Expectations | Blood test, referral, sick leave, reassurance | "Patient hopes to have blood tests done and to be reassured about the cause" |
- Choose based on the stem — in primary care, the most likely diagnosis for an undifferentiated "general malaise" is often:
- Minimum supporting evidence: ≥ 2 positive history features + 1 physical sign (e.g., conjunctival pallor for IDA, flat affect for depression)
| DDx | One Key Discriminator |
|---|---|
| Hypothyroidism | Cold intolerance + weight gain + constipation + bradycardia |
| Diabetes mellitus | Polyuria + polydipsia + weight loss despite normal/↑ appetite |
| Malignancy (e.g., lymphoma) | Unexplained weight loss + night sweats + painless lymphadenopathy |
| Domain | Example |
|---|---|
| Biological | Anaemia causing fatigue and reduced exercise tolerance |
| Psychological | Anxiety/worry about underlying serious illness; or comorbid depressive symptoms |
| Social/Functional | Inability to work / reduced work performance / burden on family / social withdrawal |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports |
|---|---|---|---|
| Iron deficiency anaemia | Conjunctival pallor | Pull down lower eyelid, inspect palpebral conjunctiva | Pallor correlates with Hb < 9-10; classic sign of anaemia [10] |
| Depression | Psychomotor retardation / flat affect | Observe during consultation: speech rate, facial expression, engagement | Supports diagnosis of major depressive disorder [4] |
| Hypothyroidism | Delayed relaxation of ankle jerks / bradycardia | Elicit ankle reflex; measure pulse | Classic clinical sign of hypothyroidism |
| Malignancy / Lymphoma | Painless, firm lymphadenopathy | Palpate cervical, axillary, inguinal LN chains systematically [5] | Non-tender, rubbery, matted LN persisting > 2 wks suggests malignancy |
| CKD / Uraemia | Peripheral oedema + café-au-lait skin colour | Inspect skin colour; press pretibial area for pitting oedema [3] | Café-au-lait skin + oedema suggests advanced CKD |
| Hepatitis / Liver failure | Jaundice (scleral icterus) | Inspect sclerae in natural light [6] | Icteric sclerae indicate hyperbilirubinaemia |
| Thyrotoxicosis | Fine tremor + tachycardia + lid lag | Outstretched hands with paper on top; check resting HR; look for lid lag | Classic triad of Graves' / thyrotoxicosis |
Top Traps That Lose Marks
- Jumping to a diagnosis without exploring ICE — the Case Report Form explicitly marks ICE; many students skip it.
- Forgetting to ask about depression — depression is the #1 masquerade for general malaise [4]. If you don't screen mood, you miss the most common diagnosis.
- Not asking about TCM / herbal medicine — patients may not volunteer this; you must ask specifically about 中成藥 (tablet form) and 中草藥 (herbal form) [6].
- Not asking about drugs — beta-blockers, statins, antihypertensives, and chemotherapy all cause fatigue.
- Ignoring red flags — unexplained weight loss, night sweats, persistent fever, new lymphadenopathy → must refer urgently.
- Writing "malaise" as the diagnosis — malaise is a symptom, not a diagnosis. Always commit to a specific most likely diagnosis.
- Forgetting to safety-net — always tell the patient when to return or go to A&E.
Must-not-miss red flags requiring urgent referral:
- Unexplained weight loss > 5% in 6 months
- Persistent fever / night sweats > 2 weeks
- New painless lymphadenopathy
- Petechiae / unexplained bruising (pancytopenia)
- Jaundice + coagulopathy (liver failure)
- Severe hyponatraemia symptoms (confusion, seizures)
Shortest safe management / safety-net line:
「如果你之後出現發高燒、嘔血、突然好攰企唔穩、或者皮膚變黃，就即刻去急症室。我會安排你驗血，一個星期後覆診睇結果。」
High Yield Summary
What to ASK: Onset/duration, constitutional symptoms (fever/night sweats/weight loss), mood screen (PHQ-2), bleeding, thyroid symptoms, polyuria/polydipsia, drug history (especially TCM), ICE, functional impact, and "Why today?"
What to WRITE: Chief complaint with timeline → HPI with system review findings → ONE RFC in patient's words → ICE explicitly → Most likely Dx with 2+ supporting features → 3 DDx with discriminators → 3 biopsychosocial problems → 1 physical sign with reasoning.
What NOT to MISS: Depression, drugs/TCM, anaemia, hypothyroidism, occult malignancy, and the hidden agenda. Malaise is never the diagnosis — always commit to a specific cause.
Active Recall - Family Medicine Clinical Test
[1] Senior notes: Block A - Fever.pdf — Constitutional symptoms and red flags for malignancy, TB, HIV [2] Senior notes: Block A - I am losing weight and sweating all the time_ causes of severe weight loss; thyrotoxicosis; hypothyroidism.pdf — Unintentional weight loss thresholds [3] Senior notes: Block A - Introduction to renal investigations_ RFT, urine tests and US kidneys.pdf — Uraemia presentation with malaise, anorexia, pruritus [4] Senior notes: Block A - Multiple joint pain_ rheumatoid arthritis and the concept of inflammatory arthritis.pdf — Depression as masquerade; psychomotor features [5] Senior notes: Block A - High white cell count_ acute and chronic leukaemia; bone marrow transplantation; immunogenetics.pdf — Bleeding, lymphadenopathy, marrow failure [6] Senior notes: Block A - Jaundice after raw oysters_ acute hepatitis.pdf — Drug/TCM hepatotoxicity masquerade [7] Lecture slides: GC 103. Fever after travelling.pdf — Travel-related infections presenting as malaise [8] Senior notes: Jerry's immunodeficiencies.pdf — HIV seroconversion and constitutional symptoms [9] Lecture slides: GC 048. Fever.pdf — Viral illness and post-viral fatigue [10] Senior notes: Block A - Abnormal bleeding after tooth extraction_ bleeding tendency; thrombocytopenia.pdf — Iron deficiency anaemia and pallor [11] Senior notes: Block A - Painful red joint_ monoarthropathy; gouty arthritis; septic arthritis; haemarthrosis.pdf — Infectious mononucleosis features [12] Senior notes: Block A - Two cases of polyuria and polydipsia.pdf — Electrolyte disturbance masquerades
Palpitations
Palpitations are the subjective awareness of one's own heartbeat, often perceived as rapid, irregular, or forceful cardiac contractions.
Oral / Dental Pain
Oral or dental pain is nociceptive or inflammatory pain arising from structures of the teeth, gingiva, oral mucosa, or jaw, most commonly caused by dental caries, pulpitis, periodontal disease, or abscess.