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Medical arithmetic: bloodshot eyes, eczema, swallowing problems


What do each of these presentations add up to? By Dr Keith Hopcroft

Case: Easy 

The patient

A 35-year-old man with no relevant past medical history and not taking any medication.

He says

‘My eye looks awful. My wife pointed it out this morning. When I look in the mirror it’s so bloodshot. I can see okay and it just feels a bit irritating.’

Subconjunctival haemorrhage

These typically cause no symptoms other than their alarming appearance, though some people mention mild irritation. Most are spontaneous but they can be caused by a vigorous cough or retch, or mild trauma. Those on warfarin should have an INR check, and there is an association with hypertension.

Case: Moderate

The patient

A 32-year-old man with a past history of eczema. Uses hydrocortisone 1% ointment as needed, plus emollients.

He says

‘My skin has got a lot worse in recent weeks and it’s so itchy. I’ve tried my usual creams but they’re not helping at all. I’m starting to wonder whether it really is eczema because it looks and feels a bit different from what I’m used to.’

Lichen planus

Not every symmetrical rash is eczema, even if the patient has a history of it. The clues here are the intensity of the itch, the lack of response to treatment and the appearance of the rash – which shows the typical violaceous polygonal papules. Note evidence of the Koebner phenomenon on the left wrist. Treatment may require potent topical steroids.

Case: Hard

The patient

A 44-year-old female who rarely attends, on no medication.

She says

‘I’ve had problems with my swallowing for a couple of years – at first on and off, but now more persistent. Sometimes it hurts, and food tends to get stuck low down. Fluids are easier to swallow, though they can make me cough and splutter.’


Dysphagia tends to make us think of, at best, a stricture secondary to GORD and, at worst, oesophageal cancer. The age group and long history are unusual, though, especially for malignancy. The endoscopy shows achalasia, a neuromuscular disorder causing a functional stenosis. Treatment can involve injection of botulinum toxin, dilatation or surgery.

Dr Keith Hopcroft is Pulse’s medical adviser and a GP in Basildon, Essex. These are hypothetical cases for illustrative purposes only