Disease and conditions 

This rhythm does not require treatment, unless they are causing symptoms, i.e. syncope, dizziness, tiredness and poor effort tolerance. Sinus bradycardia < 50/minute or sinus arrest with slow escape rhythm, accompanied by hypotension, strongly suggests a treatable underlying cause:

Fränkel’s sign is an excessive passive hip joint motion observed in tabes dorsalis, caused by reduced muscle tone around the joint.

Bitot’s spots are triangular white or foamy gray deposits on the conjunctiva at the lateral corneal margin, typically associated with vitamin A deficiency.

Hypertension is elevation of Blood Pressure (BP) measured on at least three separate occasions. There is strong association between hypertension and CAD.

Brudzinski’s sign, seen as hip and knee flexion during neck flexion, is a key indicator of meningeal irritation, often pointing to serious conditions like meningitis or subarachnoid hemorrhage. It requires prompt neurological assessment and emergency management to monitor for increased intracranial pressure and prevent deterioration.

Erb’s sign is an increased irritability of motor nerves in tetany, detected by electromyography; also refers to dullness on percussion over the manubrium in acromegaly.

Stertorous respirations are harsh, snoring-like sounds caused by partial upper airway obstruction, often seen in sleep apnea or airway edema. They signal potential respiratory compromise and require prompt assessment and airway management.

Cleeman’s sign is a slight linear depression or wrinkling of the skin above the patella, typically indicating a femoral fracture with overriding bone fragments.

Accessory muscle use refers to the engagement of extra muscles like the sternocleidomastoid and intercostals during labored breathing. It signals respiratory distress and is a key clinical sign in patients with compromised breathing.

Fajersztajn’s crossed sciatic sign: In sciatica, pain occurs on the affected side when the opposite leg is lifted. To elicit it, place the patient supine, extend the knee of the unaffected leg, and flex the hip; pain on the symptomatic side confirms a positive sign.

Nocturia is waking at night to pass excessive urine, often from renal, bladder, endocrine, or metabolic disorders, or from evening diuretics or high fluid intake.
Assessment includes history of frequency, volume, and triggers, physical exam (abdomen, flanks, bladder, prostate), urine studies, and management of underlying causes while limiting evening fluids and adjusting diuretic timing.

Aura is a brief neurological phenomenon that often precedes seizures or migraines, presenting as sensory, cognitive, or emotional changes. Recognizing aura aids in early diagnosis, timely intervention, and localization of underlying brain activity.

Apathy is a loss or suppression of emotion, motivation, or interest in personal and environmental activities, often linked to neurologic, psychiatric, or chronic systemic disorders and sometimes an early sign of serious disease.

Clavicular sign is a swelling or edema at the medial third of the clavicle, commonly associated with congenital syphilis.

Kehr’s sign is a referred left shoulder pain indicative of intraperitoneal hemorrhage, often from splenic rupture or ruptured ectopic pregnancy. It requires immediate evaluation, hemodynamic stabilization, and surgical intervention.

Ocular deviation is the abnormal movement or positioning of one or both eyes, caused by ocular, neurologic, endocrine, or systemic disorders, and may signal life-threatening conditions. Early recognition through history, eye movement assessment, and neurologic evaluation is essential for timely diagnosis and management.

Breast dimpling is a late warning sign often linked to breast cancer, caused by skin retraction over an underlying mass. It requires thorough clinical evaluation, as it may also result from infections, trauma, or fat necrosis.

Denial is an unconscious defense mechanism in which a person refuses to accept reality or facts to avoid distress; commonly seen in normal and pathological states, including the initial stage of coping with terminal illness.

Is defined as fewer than 10 breaths per minute, is a potentially life-threatening condition often caused by drug overdose, neurologic, or metabolic disorders. Immediate assessment and intervention—including airway support, monitoring, and treatment of underlying causes—are critical to prevent apnea and respiratory arrest.

Tinnitus is the perception of abnormal sounds in the ears or head, ranging from ringing to buzzing or roaring, and can be caused by ear disorders, systemic diseases, drugs, or noise exposure. Management involves identifying and treating underlying causes, protecting hearing, and using strategies such as biofeedback, masking devices, or hearing aids to improve patient adaptation.

Delbet’s sign is a presence of normal color and temperature in a limb despite absent pulses, indicating adequate collateral circulation in the context of arterial occlusion or aneurysm.

Medical causes of amenorrhea include hormonal imbalances, structural anomalies, tumors, and systemic diseases affecting the ovaries, pituitary, adrenal glands, or uterus. Symptoms often accompany amenorrhea, such as hirsutism, obesity, visual disturbances, or congenital abnormalities, depending on the underlying condition.

Polyuria is excessive urine output often caused by endocrine, renal, neurologic, or psychiatric disorders, or certain drugs, and may lead to dehydration. Evaluation focuses on fluid balance, underlying causes, and patient education on hydration and symptom monitoring.

Lead-pipe rigidity is a smooth, constant resistance to passive movement of muscles. It is typically seen in Parkinson’s disease.

Glabella tap reflex is a persistent blinking when the glabella (area between the eyebrows) is lightly tapped repeatedly. A positive reflex is seen in Parkinson’s disease, presenile dementia, and frontal lobe lesions.

Kanavel’s sign is tenderness in the palm over the tendon sheath of the little finger, indicating flexor tenosynovitis. It’s detected by applying pressure proximal to the metacarpophalangeal joint.

Mottled skin is a patchy discoloration caused by impaired dermal blood flow, ranging from benign cold-induced cutis marmorata to serious disorders such as shock or acute arterial occlusion. Prompt assessment of perfusion, pulses, and associated symptoms is essential to distinguish emergencies from chronic causes.

Butterfly rash can result from autoimmune conditions like systemic and discoid lupus erythematosus, as well as infections, dermatologic disorders, and drug reactions. Its appearance and associated symptoms vary, often involving facial erythema, scaling, and systemic signs depending on the underlying cause.

Decreased skin turgor, indicated by slow return of pinched skin, is a clinical sign of dehydration or fluid volume depletion and can result from illness, vomiting, diarrhea, or excessive fluid loss. Accurate assessment, vital sign monitoring, and prompt fluid replacement are essential, especially in children, the elderly, or critically ill patients.

Hematemesis, or vomiting of blood, indicates upper GI bleeding and may be life-threatening depending on the source, amount, and speed of bleeding. Prompt evaluation, stabilization, and management are essential, with causes ranging from peptic ulcers and varices to coagulopathies and malignancies.

Jellinek’s sign, or Rasin’s sign, is brownish pigmentation on the eyelids, more prominent on the upper lid. It indicates Graves’ disease.

Melena is black, tarry stool indicative of upper GI bleeding, requiring careful assessment for life-threatening hemorrhage. Early recognition, monitoring, and management are crucial to prevent hypovolemic shock and complications.

Excessive weight gain occurs when caloric intake exceeds energy needs or when fluid retention develops, and may result from endocrine disorders, medications, emotional factors, or reduced activity. Evaluation involves detailed history, physical examination, anthropometric measurements, and assessment of underlying medical, psychological, and lifestyle causes.

Psychotic behavior is characterized by an impaired ability to recognize reality and relate to others, manifesting as delusions, hallucinations, bizarre language, or perseveration. Management involves ensuring patient and staff safety, evaluating underlying causes, providing appropriate medication, and facilitating psychiatric care and structured activities.

Ballance’s sign is a fixed dullness in the left upper abdominal quadrant on percussion or palpation, suggestive of subcapsular or extracapsular splenic hematoma after splenic rupture.

Blepharoclonus is an excessive, involuntary blinking of the eyes, commonly associated with extrapyramidal disorders affecting the basal ganglia or cerebellum.

Heart Failure is a clinical syndrome characterized by typical symptoms that may be accompanied by signs caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.

Acute heart failure

AHF is defined as rapid or gradual onset of signs and symptoms of heart failure that results in urgent unplanned hospitalization or Emergency Medicine Department visits. The clinical signs and symptoms are significantly life threatening if the above features occur in patients with established diagnosis with structurally heart disease categorized as Acute Decompensated Heart Failure (ADHF). The cause and immediate precipitating factor(s) of the AHF must be identified and treated to prevent further damage to the heart.

Treatment Goals

To improve clinical symptoms and outcome, management strategy should be based on clinical, laboratory and haemodynamic findings. All patient with AHF should be cared and admitted to a high care dependent unit or Intensive Care Unit.

Consider oral vasodilators in case intravenous vasodilator not available or unavailability of intensive care or high dependent unit care
• Isosorbide dinitrate 10–20mg (PO) 12 hourly
OR
• Hydralazine 25 mg (PO) 6–8 hourly. Maximum dose: 200 mg/day

Inotropes (Inotropic agents)

Indicated in patients with hypotension (SBP <90 mmHg or mean arterial BP < 60mmHg) and peripheral hypoperfusion. Doses: see STG Table 20.5 (positive inotropes and vasopressors for acute heart failure).

Vasopressor (norepinephrine preferably) Indicated in patients with cardiogenic shock, despite treatment with another inotrope, to increase blood pressure and vital organ perfusion

A positive psoas sign—abdominal pain elicited by hip flexion against resistance—indicates irritation of the psoas muscle, commonly due to appendicitis or retroperitoneal abscess. Management includes prompt assessment, monitoring for complications, preparation for surgical intervention if appendicitis is suspected, and patient education.

Hypertension can develop gradually or suddenly and may signal serious underlying conditions. It is more common in women using hormonal contraceptives, especially those over 35 who smoke.

An acute pulmonary embolism, or embolus, is a blockage of a pulmonary (lung) artery. Most often, the condition results from a blood clot that forms in the legs or another part of the body (deep vein thrombosis, or DVT) and travels to the lungs.