Excessive menstrual loss: menorrhagia

Menorrhagia can be due to uterine or systemic disorders.

Some differential diagnoses and typical outline evidence

Fibroids	Suggested by: (sometimes) urinary frequency, constipation, recurrent abortion, infertility.
	Confirmed by: pelvic examination, ultrasound or CT.
	Management: OHCS pp276–7.
Endometrial carcinoma	Suggested by: abnormal uterine bleeding, blood-stained vaginal discharge, postmenopausal bleeding.
	Confirmed by: pelvic ultrasound, tissue sampling of endometrium, hysteroscopy.
	Management: OHCS pp278–9.
Pelvic endometriosis	Suggested by: dysmenorrhoea, dyspareunia, infertility, pelvic mass.
	Confirmed by: laparoscopy.
	Management: OHCS p288.
Chronic pelvic inflammatory disease	Suggested by: lower abdominal pain, fever, vaginal discharge, dysuria, ↑ ESR and ↑ CRP, leucocytosis.
	Confirmed by: high vaginal swab, pelvic ultrasound, ± laparoscopy.
	Management: OHCS p286.
Intrauterine contraceptive device	Suggested by: history of its insertion ± painful periods.
	Confirmed by: symptoms subside after removal of IUCD.
Primary hypothyroidism	Suggested by: cold intolerance, tiredness, constipation, bradycardia.
	Confirmed by: ↑ TSH, ↓ FT4.
	Management: OHCM p306.
Bleeding diathesis	Suggested by: family history, tendency to bleed, easy bruising.
	Confirmed by: abnormal clotting screen.
	Management: OHCM pp644–9.

Sudden diarrhoea, fever and vomiting

Sudden diarrhoea with fever, ± malaise, colicky abdominal pain, vomiting.

Some differential diagnoses and typical outline evidence

Antibiotic induced bacterial opportunist: Clostridium difficile	Suggested by: diarrhoea with a history of recent antibiotic therapy, ↑ WBC.
	Confirmed by: Cl. difficile toxin in stool culture.
	Management: OHCM pp218, 219.
Viral gastroenteritis: Rotavirus	Suggested by: diarrhoea in children <5>
	Management: OHCM p540.
Norwalk virus	Suggested by: diarrhoea in older children and adults, symptoms resolve in 2 weeks.
Food poisoning/ toxins Staphylococcus aureus	Suggested by: eating ‘doubtful’ meat, incubation period <6>
	Confirmed by: isolation of Staph. aureus from examination of suspected food.
	Management: OHCM p556.
Bacillus cereus	Suggested by: eating ‘doubtful’ rice, incubation period <6>
	Confirmed by: stool microscopy and culture.
	Management: OHCM pp556, 221.
Vibrio para haemolyticus	Suggested by: ‘doubtful’ seafood, incubation period 16–72 hours.
	Confirmed by: stool microscopy and culture.
	Management: OHCM pp596, 621.
Clostridium perfringens	Suggested by: eating ‘doubtful’ meat, incubation period 8–16 hours, abdominal cramps, little vomiting.
	Confirmed by: organism isolation from faeces or suspected food.
Botulism	Suggested by: eating ‘doubtful’ canned food, incubation period 18–36 hours, but may vary from 4 hours to 8 days, abdominal cramps, dry mouth, diplopia, progressive paralysis.
	Confirmed by: C. botulinum toxin in serum or faeces; C. botulinum toxin isolation from suspected food.
	Management: OHCM pp591, 830.
Salmonella typhimurium	Suggested by: eating ‘doubtful’ meat, egg, poultry. Fever (with relative bradycardia), headache, dry cough.
	Confirmed by: stool microscopy and culture.
	Management: OHCM p596.