The workup of bad breath involves a careful examination of the mouth and nasal passages. If this is negative, chest and sinus x-rays and upper GI series with barium swallow should be done. If the studies are still unrewarding, then endoscopy of the respiratory and upper GI tract would be indicated. Appropriate liver and renal function tests will be ordered when uremia or hepatic coma is suspected. If pyorrhea is suspected, refer the patient to a dentist.

In the workup of hallucinations, it is essential to get a drug history from a relative or friend if not from the patient. Ask about a family history of epilepsy or head trauma. A drug screen should be ordered. If there is no mental deterioration, referral to a psychiatrist may be done but an electroencephalogram (EEG) may still be indicated. A therapeutic trial of 100 mg of thiamine IV should be done if Wernicke encephalopathy or Korsakoff syndrome is suspected. With mental deterioration, a neurologist should be consulted. When there is doubt about mental deterioration, psychologic testing may be done. Computed tomography (CT) or MRI scans, EEGs, skull x-ray films, and arteriograms may be necessary in selected cases.

In diagnosis, most of these conditions will be obvious on inspection. The difficulty arises when the hand looks normal. Then one must check for the following:

The patient presenting with a history of headaches is an exciting diagnostic challenge. If one approaches the challenge simply on the basis of what is common, the patient most likely has migraine or muscle traction headache. But, wait a minute! Shouldn’t we look for serious conditions such as brain tumor, meningitis, or subarachnoid hemorrhage to avoid a serious mistake and a malpractice suit? First, check for nuchal rigidity to rule out meningitis and subarachnoid hemorrhage. Next, do a careful neurologic examination to rule out a brain tumor or other space-occupying lesion. These steps are particularly important in a patient who is experiencing his or her first serious headache. If there is nuchal rigidity or focal neurologic signs, it is wise to immediately refer the patient to a neurologist or neurosurgeon for further workup and possible hospitalization. The specialist will probably order a CT scan of the brain and follow that with a spinal tap if a subarachnoid hemorrhage or meningitis is suspected. It is clear that a CT scan should be done prior to a spinal tap if there are focal neurologic signs or papilledema. One other condition that must be considered in acute headache (particularly in elderly persons) is temporal arteritis. A sedimentation rate will usually be positive, but a neurology consult is axiomatic so that steroids can be started immediately.

In the patient with chronic or recurring headaches and no neurologic findings, it is wise to see the patient during the attack. Migraine headaches are typically associated with an aura or photophobia. Visual acuity should always be checked. Migraine and histamine headaches can be diagnosed by the response to sumatriptan by mouth or injection. If the headaches are due to chronic allergic or infectious rhinitis, relief can be had by spraying the turbinates with phenylephrine. Muscle traction headaches will often be relieved by occipital nerve blocks supporting the diagnosis. Compression of the superficial temporal artery will often relieve migraine temporarily supporting that diagnosis. Compression of the jugular veins will often give relief to patients with postspinal tap headaches.

If the patient is seen between headaches, certain prophylactic measures may help establish the diagnosis. For migraine, β-blockers may be prescribed; if the headaches are prevented, there is good support for the diagnosis. A course of corticosteroids may be initiated in patients with histamine (cluster) headaches to help establish the diagnosis. Muscle relaxants and/or tricyclic drugs may be given to help diagnose muscle contraction headaches.

The diagnostic workup of chronic headaches might include a CT scan of the brain, x-rays or CT scans of the sinuses, x-rays of the cervical spine, and routine blood work. Certainly if headache persists after careful follow-up, these need to be done. An ophthalmologist should be consulted to rule out astigmatism and glaucoma.

Obviously, the most important thing in the workup of this symptom is a good neurologic examination and a skull x-ray film. Other studies will be dictated by the findings of the above. A blood count and morphology study will be worthwhile if Cooley anemia is suspected and Wassermann or fluorescent treponemal antibody absorption (FTA-ABS) test if congenital syphilis is suspected. Positional head deformity is most commonly caused by a child sleeping frequently in the supine position.

The approach to the diagnosis includes excision or biopsy of skin lesions, skull x-rays, CT scans, bone scans, and, if necessary, a bone biopsy. A neurosurgeon should be consulted before ordering expensive diagnostic tests.

The approach to the diagnosis of heartburn is similar to that of any GI complaint, but a few clinical tricks will help decide whether it is intrinsic or extrinsic, especially if the upper GI series is negative. Always order an esophagram. If the patient has the pain when in your office, administer a tablespoon or two of lidocaine (Xylocaine viscous). If the patient gets relief in 5 to 10 minutes, the heartburn is probably caused by esophagitis. Further confirmation can be obtained by a Bernstein test. In this test, solutions of normal saline and 0.10 normal HCl are administered by intravenous tubing into the lower esophagus, alternating one with the other. If the patient invariably experiences pain when the 0.10 normal HCl is administered, esophagitis is confirmed. Esophagoscopy and gastroscopy will reveal most intrinsic lesions with certainty, but occasionally they are normal in esophagitis. Manometric studies of the esophagus are the best way to diagnose esophageal reflux. If the episodes are frequent but relatively brief, a trial of nitroglycerin may diagnose angina pectoris. Coronary insufficiency may also be confirmed by an exercise tolerance test. Cholecystogram and liver and pancreatic function studies may also be indicated.

When confronted with solid evidence of hematemesis, the clinician should not waste valuable time on a thorough history and physical examination when endoscopy is more important in both diagnosis and therapy. Ordering a type and cross for multiple units of blood, coagulation studies, and the other tests listed below should also be done immediately in most cases. History of alcoholism, use of aspirin and other drugs, and previous ulcers or esophageal disease is important to get while preparing for endoscopy and other emergency procedures. Patients without massive or recent acute hematemesis or melena may be approached with traditional methods. A history of vomiting nonhemorrhagic gastric fluid before the onset of hematemesis is helpful in diagnosing a Mallory–Weiss syndrome. Remember black stools can be caused by Pepto-Bismol, iron, spinach, or licorice ingestion.

The clinical picture will point to the diagnosis in many cases. If there is a history of abdominal trauma, a contusion or laceration of the kidney or bladder should be suspected. Massive trauma anywhere prompts a tentative diagnosis of crush syndrome. This will cause myoglobinuria as well as hematuria. Purpura or bleeding from other sites suggests a coagulation disorder. Severe colicky pain in the abdomen suggests kidney stone. A long history of hypertension suggests polycystic kidneys, renal artery stenosis, or glomerulonephritis. A history of fever and rheumatic valvular disease suggests SBE with renal embolism. Painless hematuria in an otherwise healthy-looking adult suggests neoplasm, whereas painful hematuria with frequency and dysuria suggests cystitis. Hematuria and a flank mass would make a neoplasm or polycystic kidney likely. Red cell casts in the sediment indicate the bleeding is coming from the kidney. No red cells in the presence of a positive dipstick test for blood indicates hemoglobinuria. Clots in the urine should suggest that the lesion is in the bladder.

The initial workup should include a CBC, urinalysis, urine culture, chemistry panel, flat plate of the abdomen to assess the presence of stones and kidney size, and personal examination of the urinary sediment. If a renal calculus is suspected, a noncontrast helical CT scan is ordered immediately, and an urologist consulted. A three-glass test will help to localize the site of the bleeding. If there is blood in the initial specimen only, the urethra is probably the site of bleeding. If the blood is primarily in the final specimen, the bladder is most likely the site of bleeding. Equal blood discoloration in all specimens points to a renal lesion.

If renal TB is suspected, an acid-fast bacillus (AFB) smear and culture is done. If collagen disease is suspected, an ANA analysis and anti–double-strand DNA antibody titer is ordered.

If a renal carcinoma is suspected, a CT scan of the abdomen is probably the best study to order, but the advice of an urologist ought to be sought. Ultrasonography is useful in differentiating cysts from tumors. If a bladder neoplasm is suspected, cystoscopy will be done. If renal artery embolism or thrombosis is suspected, renal angiography may need to be done to clearly make the diagnosis.