Others (In Murtagh)
Erectile Dysfunction
Erectile dysfunction is the persistent inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Vasculogenic ED (atherosclerosis, HTN, DM) [1][2] | Gradual onset, absent morning erections, vascular RF present | 「你有冇糖尿、高血壓、高膽固醇？朝早有冇自然硬起嚟？」 | ~40% |
| Psychogenic ED (performance anxiety, stress) | Sudden onset, situational, preserved morning erections | 「係咪某啲情況先有困難？自慰嗰陣OK唔OK？」 | ~25% | |
| Serious Not To Miss | Prostate/pelvic malignancy (post-treatment) | Hx of surgery/radiation, LUTS, weight loss | 「有冇前列腺嘅問題或者做過手術？」 | ~2% |
| Pituitary tumour / prolactinoma | Headache, visual field defect, ↓libido, galactorrhoea | 「有冇頭痛、睇嘢矇咗、或者胸部流嘢出嚟？」 | ~1% | |
| Leriche syndrome (aortoiliac occlusion) [4] | Buttock claudication + absent femoral pulses + ED | 「行路嗰陣臀部有冇痛？」; check femoral pulses | < 1% | |
| Pitfalls | Drug-induced ED | Temporal link with starting medication | 「你幾時開始食呢隻藥？同ED開始嘅時間夾唔夾？」 | ~15% |
| Hypogonadism (primary or secondary) | ↓Libido, fatigue, ↓body hair, small/soft testes | 「有冇覺得成日攰、冇精神？鬚有冇少咗？」; examine testes | ~8% | |
| Peyronie's disease | Penile curvature, palpable plaque, pain on erection | 「硬起嚟嗰陣有冇彎曲或者痛？」 | ~3% | |
| Masquerades | Depression | Low mood, anhedonia, sleep disturbance, ↓libido | 「你最近有冇覺得做咩都冇興趣？瞓得好唔好？」 | ~15% |
| Diabetes mellitus [2][7] | Polyuria, polydipsia, weight loss, known DM | 「有冇成日口渴、去廁所多咗、體重輕咗？」 | ~10% | |
| Hypothyroidism | Fatigue, weight gain, cold intolerance, constipation | 「有冇覺得特別怕凍、體重重咗、便秘？」 | ~2% | |
| Trying to Tell Me Something? | Marital/relationship crisis | Partner pressure, affair, loss of intimacy | 「你同伴侶嘅關係最近有冇變化？」 | ~15% |
| Fear of cancer / serious disease | Health anxiety | 「你有冇擔心呢個問題係因為嚴重嘅病？」 | ~10% | |
| Non-compliance with meds to preserve erections [3] | Stops antihypertensives intermittently | 「你有冇因為擔心影響性功能而停過藥？」 | ~5% |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, build rapport, set agenda | 「你好，我係X醫生。今日有咩可以幫到你呀？」「多謝你嚟睇醫生，我哋傾下先。」 | Warm greeting + open question scores interpersonal marks; establishes trust for sensitive topic |
| 0:30–1:00 | Elicit chief complaint; let patient tell their story | 「你可唔可以講多少少，大概係咩情況呀？」「幾耐之前開始㗎？」 | Open-ended → patient leads; avoid jumping to assumptions |
| 1:00–2:30 | Symptom analysis & key history | 「你朝早瞓醒嗰陣有冇自然勃起呀？」(morning erections) 「係所有情況都有困難，定係某啲情況先有？」(generalised vs situational) 「有冇食緊咩藥呀？例如血壓藥、糖尿藥、情緒藥？」 | Discriminates organic vs psychogenic [1][2]; drug history is high-yield |
| 2:30–3:30 | Red flags, PMH, risk factors | 「有冇糖尿病、高血壓、高膽固醇呀？」「有冇心臟病或者做過手術？」「你有冇覺得心情差、壓力大呀？」「有冇飲酒或者食煙嘅習慣？」 | Screens vascular RF, depression masquerade, lifestyle factors |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得呢個情況係咩原因呢？」(Ideas) 「你最擔心嘅係咩呀？」(Concerns) 「你今日嚟睇醫生，最希望我可以點樣幫你呀？」(Expectations) 「點解揀咗今日嚟呢？」(Why today → hidden agenda) | ICE is directly tested on case report; "why today" uncovers hidden agenda (e.g. marital tension, fear of serious disease, partner pressure) |
| 4:30–5:15 | Social/functional impact, sexual/relationship Hx | 「呢個問題有冇影響你同太太/伴侶嘅關係？」「工作方面有冇受影響？壓力大唔大？」 | Biopsychosocial assessment; relationship impact is a key social problem |
| 5:15–5:45 | Summarise back, check understanding | 「等我總結一下⋯你嘅情況大概係⋯我有冇漏咗啲咩？」 | Shows active listening; corrects misunderstandings |
| 5:45–6:00 | Safety net & close | 「如果你突然覺得胸口痛或者心情好差，記得即刻嚟睇醫生。我哋之後會安排抽血檢查，下次覆診再傾。」 | Safe closure; addresses CV risk screening |
Uncovering the hidden agenda: The presenting symptom is ED, but the real reason for consultation may be: marital/relationship crisis, fear of prostate cancer, partner's pressure to conceive, non-compliance with antihypertensives to preserve erections [3], depression, or anxiety about masculinity. Always ask 「點解揀咗今日嚟呢？」 and 「有冇其他嘢想同我傾？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & duration | When did ED start? Gradual or sudden? | 「幾時開始有呢個問題？係慢慢嚟定突然間㗎？」 | Gradual → organic; sudden → psychogenic [1][2] | Organic vs psychogenic |
| Morning erections | Do you still get morning erections? | 「朝早瞓醒嗰陣有冇自然硬起嚟？」 | Preserved morning erections suggest psychogenic cause; absent suggests organic [2] | Psychogenic (preserved) vs organic (absent) |
| Situational vs generalised | Does it happen with all partners/situations or only certain ones? | 「係所有情況都有困難，定係某啲情況先有呢？例如自慰嗰陣OK唔OK？」 | Situational → psychogenic; generalised → organic [1] | Psychogenic if situational |
| Libido | Has your sex drive changed? | 「你對性方面嘅興趣有冇減少？」 | ↓Libido → hypogonadism, depression, hyperprolactinaemia | Endocrine cause, depression |
| Ejaculation | Any problems with ejaculation? | 「射精方面有冇問題？例如太快、太遲、或者射唔到？」 | Retrograde ejaculation (DM), premature ejaculation (anxiety) | DM autonomic neuropathy, anxiety |
| Relationship | How is your relationship with your partner? | 「你同太太/伴侶嘅關係點呀？」 | Relationship conflict is a major psychogenic cause | Psychogenic ED, hidden agenda |
| Mood/stress | Are you feeling low, stressed, or anxious? | 「你最近心情點呀？有冇覺得好大壓力或者唔開心？」 | Depression is a masquerade [2]; performance anxiety common | Depression, anxiety disorder |
| PMH – vascular RF | DM, HTN, hyperlipidaemia, IHD? | 「你有冇糖尿、高血壓、高膽固醇、心臟病？」 | Vascular disease is the commonest organic cause [1][2] | Vasculogenic ED |
| Drug history | What medications are you taking? | 「你而家食緊咩藥？有冇食血壓藥、情緒藥、胃藥？」 | Thiazides, β-blockers, SSRIs, antiandrogens can cause ED [2] | Drug-induced ED |
| Smoking & alcohol | Do you smoke or drink? | 「你有冇食煙飲酒嘅習慣？」 | Smoking → vasculogenic; alcohol → hypogonadism, neuropathy [5] | Vasculogenic, alcoholic neuropathy |
| Neurological Sx | Any numbness/tingling in hands/feet? Bladder problems? | 「手腳有冇痺或者冇感覺？小便有冇困難？」 | Peripheral/autonomic neuropathy (DM), spinal cord pathology | Neurogenic ED |
| Endocrine Sx | Visual changes? Headaches? Galactorrhoea? | 「有冇頭痛、睇嘢矇咗、或者胸部有液體流出？」 | Hyperprolactinaemia from pituitary tumour [6] | Prolactinoma |
| Claudication | Pain in buttocks/legs when walking? | 「行路嗰陣臀部或者腳有冇痛？」 | Leriche syndrome: buttock claudication + absent femoral pulses + ED [4] | Aortoiliac disease |
| Surgical Hx | Any pelvic/prostate surgery or radiation? | 「有冇做過前列腺手術或者盆腔手術？」 | Nerve damage → neurogenic ED | Iatrogenic neurogenic ED |
| Family Hx | Family history of DM, heart disease? | 「屋企人有冇糖尿病或者心臟病？」 | Identifies CV risk | Vascular RF |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Safety; mandatory for case report | — |
Case Report Form Answer Builder
- CC: Erectile dysfunction × [duration]
- HPI must include: onset (gradual/sudden), duration, severity (unable to achieve vs unable to maintain), presence/absence of morning erections, situational vs generalised, libido, ejaculation function, relationship context, vascular RF (DM/HTN/hyperlipidaemia/smoking), medications, mood, functional impact
- Examples: "Patient wants to know why he has difficulty achieving erection and seeks treatment" / "Patient came because wife is unhappy with sexual life" / "Patient worried ED is a sign of serious disease"
- Tip: Frame it as the patient's agenda, not the medical problem. Use "Why today?" to identify the best single answer.
| Likely Examples | Exact Wording | |
|---|---|---|
| Ideas | "I think it might be because of my diabetes/medication/age/stress" | "Patient thinks ED is due to his diabetes medications" |
| Concerns | "I'm worried it means I have a serious disease / my marriage is affected / I'm not a real man" | "Patient is worried that ED will ruin his marriage" |
| Expectations | "I want Viagra / I want blood tests / I want a referral" | "Patient hopes to receive medication (e.g. PDE5 inhibitor) to improve erections" |
- In primary care: Vasculogenic ED secondary to atherosclerotic risk factors (DM, HTN, hyperlipidaemia, smoking) [1][2]
- Minimum supporting evidence: gradual onset, absent morning erections, presence of vascular risk factors, no situational variation
- If history suggests sudden onset + preserved morning erections + situational → Psychogenic ED
| DDx | Key Discriminator |
|---|---|
| 1. Psychogenic ED | Sudden onset, situational, preserved morning erections, identifiable stressor |
| 2. Drug-induced ED | Temporal correlation with medication (β-blocker, thiazide, SSRI) [2] |
| 3. Hypogonadism (primary/secondary) | ↓Libido, fatigue, ↓body hair, small/soft testes; check testosterone |
| Domain | Problem |
|---|---|
| Biological | Underlying vascular risk factors (DM/HTN/hyperlipidaemia) inadequately controlled |
| Psychological | Performance anxiety / depression / low self-esteem secondary to ED |
| Social | Marital/relationship strain; possible medication non-compliance affecting BP control [3] |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Vasculogenic ED (most likely) | Absent/diminished peripheral pulses (dorsalis pedis, posterior tibial, femoral) | Palpate bilateral femoral, popliteal, dorsalis pedis, posterior tibial arteries | Indicates atherosclerotic peripheral arterial disease → same process affects penile arteries |
| Leriche syndrome | Absent bilateral femoral pulses [4] | Palpate femoral arteries at inguinal crease | Triad: buttock claudication + absent femoral pulses + ED |
| Hypogonadism | Small, soft testes | Palpate testes for size and consistency | Testicular atrophy suggests ↓testosterone production [6] |
| Psychogenic ED | No reliable physical sign in brief FM station | Normal cardiovascular and genital exam; diagnosis by history (preserved morning erection, situational) | Diagnosis of exclusion supported by normal examination |
| Drug-induced ED | No specific physical sign | Review medication chart; temporal link | Diagnosed by history and medication review, not examination |
| Hyperprolactinaemia | Bitemporal hemianopia (if macroadenoma) | Confrontation visual field testing | Pituitary macroadenoma compressing optic chiasm [6] |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to ask about morning erections — this is THE key discriminator between organic and psychogenic ED [2]
- Not asking about medications — β-blockers, thiazides, SSRIs, antiandrogens are common culprits [2]
- Missing the hidden agenda — patient may be non-compliant with antihypertensives to preserve erections [3]; partner may have pushed them to come
- Not exploring ICE — ICE is directly scored; always ask all three
- Labelling as "just psychological" — 50% of ED is organic; most patients need blood glucose, lipid profile, hormones, ECG [2]
- Forgetting depression screen — depression is both a cause and a consequence of ED
- Not checking vascular risk factors — ED is an early marker of cardiovascular disease; miss this = miss serious diagnosis
- Sudden onset ED + perineal/saddle anaesthesia + urinary retention → Cauda equina syndrome → Emergency referral
- ED + bitemporal hemianopia + headache → Pituitary tumour → Urgent MRI + endocrine referral
- ED + buttock claudication + absent femoral pulses → Leriche syndrome → Vascular surgery referral [4]
- ED + chest pain on exertion → IHD → Cardiology workup (note: do NOT prescribe PDE5 inhibitors with nitrates — absolute contraindication)
「我哋會安排抽血檢查糖尿、膽固醇、荷爾蒙，同埋做心電圖。如果你有胸口痛或者情緒好差，記得即刻返嚟。我哋下次覆診會同你商量治療方案。」
High Yield Summary
What to ASK: Morning erections (organic vs psychogenic), onset pattern, medications (β-blockers/thiazides/SSRIs), vascular RF (DM/HTN/HLD/smoking), mood, relationship, ICE, "why today?"
What to WRITE: CC with duration; gradual vs sudden onset; morning erections present/absent; vascular RF; medication list; ICE verbatim; most likely diagnosis = vasculogenic ED (or psychogenic if history fits); DDx = psychogenic / drug-induced / hypogonadism; biopsychosocial = uncontrolled vascular RF / performance anxiety or depression / marital strain; physical sign = absent peripheral pulses
What NOT to MISS: Morning erection question, medication-induced ED, depression masquerade, Leriche syndrome, non-compliance with antihypertensives [3], PDE5i-nitrate contraindication, cauda equina red flags
Active Recall - Family Medicine Clinical Test
[1] GC 184. Erection and erectile dysfunction.pdf (Classification of ED: organic vs psychogenic) [2] MBBS4 Sexual function t Dysf140824.pdf (Organic causes, psychogenic causes, morning erections as discriminator, investigations needed) [3] MBBS4 t Sexual problems in GP160925.pdf (Non-compliance with antihypertensives to protect erections, sex in HTN and DM) [4] MBBS Final MB (Surgery) (Felix PY Lai).pdf p932 (Leriche syndrome triad) [5] Ryan Ho GI.pdf p304, p312 (Alcohol-related hypogonadism/ED, cirrhosis endocrine changes) [6] Ryan Ho Endocrine.pdf p110 (Hyperprolactinaemia causing ED, hypogonadism) [7] Maksim Medicine Notes.pdf p89 (Diabetic autonomic neuropathy causing ED)
Epistaxis
Bleeding from the nasal cavity, most commonly originating from the Kiesselbach plexus on the anterior nasal septum.
Facial Pain
Facial pain is an unpleasant sensory experience localized to the face, arising from neurological, vascular, musculoskeletal, or sinus-related etiologies such as trigeminal neuralgia, temporomandibular disorders, or sinusitis.