System

Examples

Constitutional symptoms

unexplained weight loss, night sweats, fatigue/malaise/lethargy, sleeping pattern, appetite, fever, itch/rash, recent trauma, lumps/bumps/masses, unexplained falls

Eyes

visual changes, headache, eye pain, double vision, scotomas (blind spots), floaters or "feeling like a curtain got pulled down" (retinal hemorrhage vs amaurosis fugax)

Runny nose, frequent nose bleeds (epistaxis), sinus pain, stuffy ears, ear pain, ringing in Ears, nose, mouth, and ears (tinnitus), gingival bleeding, toothache, sore throat, pain with swallowing throat (ENT) (odynophagia)

Cardiovascular

chest pain, shortness of breath, exercise intolerance, PND, orthopnoea, oedema, palpitations, faintness, loss of consciousness, claudication

Respiratory

cough, sputum, wheeze, haemoptysis, shortness of breath, exercise intolerance

Gastrointestinal

abdominal pain, unintentional weight loss, difficulty swallowing (solids vs liquids), indigestion, bloating, cramping, anorexia, food avoidance, nausea/vomiting,diarrhea/constipation, inability to pass gas (obstipation), vomiting blood (haematemesis), bright red blood per rectum (BRBPR, hematochezia), foul smelling dark black tarry stools (melaena), dry heaves of the bowels (tenesmus)

Genitourinary

Urinary: Irritative vs Obstructive symptoms: Micturition incontinence, dysuria, haematuria, nocturia, polyuria, hesitancy, terminal dribbling, decreased force of stream Genital: Vaginal discharge, pain, Menses - frequency, regularity, heavy or light (ask about excessive use of pads/tampons, staining of clothes, clots always indicate heavy bleeding), duration, pain, first day of last menstrual period (LMP), gravida/para/abortus, menarche, menopause, contraception (if relevant), date of last smear test and result

Musculoskeletal

pain, misalignment, stiffness (morning vs day long; improves/worsens with activity), joint swelling, decreased range of motion, crepitus, functional deficit, arthritis

Integumentary/Breast

pruritus, rashes, stria, lesions, wounds, incisions, acanthosis nigricans, nodules, tumors, eczema, excessive dryness and/or discoloration. Breast pain, soreness, lumps, or discharge.

Neurological

Special senses - any changes in sight, smell, hearing and taste, seizures, faints, fits, funny turns, headache, pins and needles (paraesthesiae) or numbness, limbweakness, poor balance, speech problems, sphincter disturbance, higher mental function and psychiatric symptoms

Psychiatric

depression, sleep patterns, anxiety, difficult concentrating, body image, work and school performance, paranoia, anhedonia, lack of energy, episodes of mania, episodic change in personality, expansive personality, sexual or financial 'binges',

Endocrine

Hyperthyroid: prefer cold weather, mood swings, sweaty, diarrhoea, oligomenorrhoea, weight loss despite increased appetite, tremor, palpitations, visual disturbances; Hypothyroid - prefer hot weather, slow, tired, depressed, thin hair, croaky voice, heavy periods, constipation, dry skin Diabetes: polydipsia, polyuria, polyphagia (constant hunger without weight gain is more typical for a type I diabetic than type II), symptoms of hypoglycemia such as dizziness, sweating, headache,hunger, tongue dysarticulation Adrenal: difficult to treat hypertension, chronic low blood pressure, orthostatic symptoms, darkening of skin in non-sun exposed places Reproductive (female): menarche, cycle duration and frequency, vaginal bleeding irregularities, use of birth control pills Reproductive (male): difficulty with erection or sexual arousal, depression, lack of stamina/energy

anemia, purpura, petechia, results from routine hemolytic diseases screening, prolonged or excessive bleeding after dental extraction / injury, use of anticoagulant and Hematologic/lymphatic antiplatelet drugs (including aspirin), family history of hemophilia, history of a blood transfusion, refused for blood donation

Allergic/immunologic

"Difficulty breathing" or "choking" (anaphylaxis) as a result of exposure to anything (and state what; e.g. "bee sting"). Swelling or pain at groin(s), axilla(e) or neck (swollenlymph nodes/glands), allergic response (rash/itch) to materials, foods, animals (e.g. cats); reaction to bee sting, unusual sneezing (in response to what), runny nose or itchy/teary eyes; food, medication or environmental allergy test(s) results.

Splenomegaly is an enlargement of the spleen. The spleen usually lies in the left upper quadrant (LUQ) of the human abdomen. It is one of the four cardinal signs of hypersplenism, some reduction in the number of circulating blood cells affecting granulocytes, erythrocytes or platelets in any combination; a compensatory proliferative response in the bone marrow; and the potential for correction of these abnormalities

by splenectomy. Splenomegaly is usually associated with increased workload (such as in hemolytic anemias), which suggests that it is a response to hyperfunction. It is therefore not surprising that splenomegaly is associated with any disease process that involves abnormal red blood cells being destroyed in the spleen. Other common causes include congestion due to portal hypertension and infiltration by leukemias and lymphomas. Thus, the finding of an enlarged spleen; along with caput medusa; is an important sign of portal hypertension Definition Poulin et al. classify splenomegaly as: Moderate splenomegaly, if the largest dimension is between 1120 cm Severe splenomegaly, if the largest dimension is greater than 20 cm Splenomegaly refers strictly to spleen enlargement, and is distinct from hypersplenism, which connotes overactive function by a spleen of any size. Splenomegaly and hypersplenism should not be confused. Each may be found separately, or they may coexist. Clinically if a spleen is palpable, it means it is enlarged as it has to undergo enlargement by at least twofolds to become palpable. However, the tip of the spleen may be palpable in a newborn baby up to 3 months of age. Symptoms and signs Symptoms may include abdominal pain, chest pain, chest pain similar to pleuritic pain when stomach, bladder or bowels are full, back pain, early satiety due to splenic encroachment, or the symptoms of anemia due to accompanying cytopenia. Signs of splenomegaly may include a palpable left upper quadrant abdominal mass or splenic rub. It can be detected on physical examination by using Castell's sign or Traube's space, but an ultrasound can be used to confirm diagnosis. In patients where the likelihood of splenomegaly is high, the physical exam is not sufficiently sensitive to detect it; abdominal imaging is indicated in such patients. Causes The most common causes of splenomegaly in developed countries are infectious mononucleosis, splenic infiltration with cancer cells from a hematological malignancy and portal hypertension (most commonly secondary to liver disease, and Sarcoidosis). Splenomegaly may also come from bacterial infections, such as syphilis or an infection of the heart's inner lining (endocarditis).
[4] [3] [2]

The possible causes of moderate splenomegaly (spleen <1000 g) are many, and include: Splenomegaly grouped on the basis of the pathogenic mechanism

Increased function

Abnormal blood flow

Infiltration

Organ Failure Removal of defective RBCs spherocytosis thalassemia hemoglobinopathies nutritional anemias early sickle cell anemia Vascular hepatic vein obstruction cirrhosis

Metabolic diseases Gauchers disease NiemannPick disease alpha-mannosidosis Hurler syndrome and other mucopolysaccharidoses amyloidosis Tangier disease
[7]

portal vein obstruction BuddChiari syndrome splenic vein obstruction

Immune hyperplasia Response to infection (viral, bacterial, fungal, parasitic) mononucleosis, AIDS, viral hepatitis subacute bacterial endocarditis, bacterial septicemia splenic abscess, typhoid fever brucellosis, leptospirosis, tuberculosis histoplasmosis malaria, leishmaniasis, trypanosomiasis ehrlichiosis
[6] [5]

Benign and malignant infiltrations leukemias (acute, chronic, lymphoid, and myeloid) lymphomas (Hodgkins and nonHodgkins) myeloproliferative disease metastatic tumors (commonly melanoma) histiocytosis X hemangioma, lymphangioma splenic cysts hamartomas eosinophilic granuloma littoral cell angioma
[8][9][10]

Infections hepatic schistosomiasis hepatic echinococcosis

Disordered immunoregulation rheumatoid arthritis Systemic lupus erythematosus serum sickness autoimmune hemolytic anemia sarcoidosis drug reactions

Extramedullary hematopoiesis myelofibrosis marrow infiltration by tumors, leukemias marrow damage by radiation, toxins

The causes of massive splenomegaly (spleen >1000 g) are fewer, and include:

visceral leishmaniasis (kala-azar) chronic myelogenous leukemia myelofibrosis malaria primary lymphoma of spleen

Treatment If the splenomegaly underlies hypersplenism, a splenectomy is indicated and will correct the hypersplenism. However, the underlying cause of the hypersplenism will most likely remain; consequently, a thorough diagnostic workup is still indicated, as, leukemia, lymphoma and other serious disorders can cause hypersplenism and splenomegaly. After splenectomy, however, patients have an increased risk for infectious diseases. Patients undergoing splenectomy should be vaccinated against Haemophilus influenzae, Streptococcus pneumoniae, and Meningococcus. They should also receive annual influenza vaccinations. Longterm prophylactic antibiotics may be given in certain cases. SplenomegalySchistosomiasisThis is prevalent in Africa (particularly around the Nile delta), Asia and South America.It is caused by infection with Schistosoma mansoni in nearly 75 per cent of cases and bySchistosoma haematobium in the remainder. Splenic enlargement is produced byhyperplasia which is induced by phagocytosis of disintegrated worms, ova and toxins,and by portal hypertension which is the result of hepatic fibrosis.Clinical featuresSplenomegaly arising from schistosomiasis can occur at any age and is more prevalent inmales. The degree of splenic enlargement reflects the extent of hepatic fibrosis and maybe massive.InvestigationsThe urine and faeces are examined for ova. Liver function tests reveal a varying degree of hepatic impairment. A hypochromic anaemia is always present.TreatmentSuccessful medical treatment of established cases does not result in regression of thesplenomegaly. Removal of the painful and bulky spleen is indicated where there is noevidence of hepatic or renal insufficiency. If ascites is present, a portosystemic shuntshould be combined with splenectomy.Tropical splenomegalyMassive enlargement of the spleen occurs frequently in the tropics, for example inmalaria (especially in children), kalaazar and schistosomiasis (see above). In parts of Africa and New Guinea splenomegaly cannot be fully attributed to these diseases becausetropical splenomegaly is restricted to only a few adults in areas where malaria is endemic.The most likely explanation is an abnormal immune response to malaria or unusualspecies of plasmodia. Malnutrition may also be a factor and there is a high incidence This is associated with anaemia due toshortened red cell life and thrombocytopenia due to splenic sequestration of platelets,which respond to splenectomy. Splenectomy is indicated for those disabled by anaemiaor by the weight of an enormous spleen. Splenectomy reduces immunity to malaria andtherefore antimalarial chemotherapy (e.g. proguanil) should follow splenectomy inmalaria endemic areas and be maintained for life.Hypersplenism due to portal hypertensionSplenomegaly invariably accompanies portal hypertension. This splenic enlargementresults in thrombocytopenia (due to splenic sequestration of platelets) andgranulocytopenia. These are permanently relieved when splenectomy accompaniesoperation for the relief of portal hypertension. Shunt surgery alone does not have thesame effect.Feltys syndromeA moderate number of patients with chronic rheumatoid arthritis develops mildleucopenia; in a few of these, neutropenia becomes extreme and is usually associatedwith enlargement of the spleen; this combination is referred to as Feltys syndrome. Aremarkable characteristic of this syndrome is that the leucopenia and splenic enlargementare apparently unrelated to the severity of the arthritic changes; indeed, in some instancesthe arthritis has begun to improve or has become quiescent by the time the low white cell.