Murtagh – PROMPT Model

The Murtagh diagnostic model consists of 5 questions

1. What are the probability diagnoses?
2. What serious disorders should not be missed? (Red Flags)
3. What are the pitfalls? (Often missed)
4. Does the patient have one of the classic masquerades?
5. Is the patient trying to tell me something else?

This is also called the PROMPT model 

• P – Probability, i.e. What are the most likely and common diagnoses?
• R – Red flag conditions, i.e. What serious disorders are not to be missed?
• O – Often missed (pitfalls), i.e. pregnancy, drugs, allergies, constipation, menopause
• M – Masquerades, i.e. depression, drugs, diabetes, anaemia, thyroid, UTI, spinal
• PT – Is this Patient trying to Tell me something else?

Red Flags

Professor Murtagh lists the following items as red flags, which, if present, demand extra attention. I’ve added severe pain to this list. RASCAL FACTS WIN is a mnemonic.

1. Representation or failure to improve
2. Acute onset
3. Severe pain
4. Cancer hx
5. Age > 50
6. Loss of Weight
7. Fever > 37.8
8. Altered bowel/urine habit, vomiting, dysphagia
9. Cognitive changes and neurological deficits
10. Travel Hx (overseas)
11. Syncope on the toilet
12. White appearance (Pallor)
13. Immunocompromised, i.e. steroids, biologicals, methotrexate, carbimazole
14. Narcotics, IVDU, drug or alcohol abuse

Serious not to be missed (VINAS)

1. Vascular
   • arterial
     • acute coronary syndromes
     • cerebral, e.g. stroke, SAH
     • aneurysms—aortic, cerebral
   • venous
     • DVT → pulmonary embolus
     • axillary venous thrombosis
   • arteritis—GCA/temporal,
   • vasculitides
   • bleeding, e.g. ectopic, DIC
2. Infection
   • septicaemia
   • meningoencephalitis
   • meningococcus
   • infective endocarditis
   • HIV/AIDS
   • clostridia infections e.g.tetanus
   • pneumonia/avian flu/SARS
   • haemorrhagic fever
3. Neoplasia
4. Asthma
5. Suicide – Imminent or potential suicide

Often Missed (Pitfalls)

1. Addison disease
2. Allergies
3. Abscess (hidden)
4. Candida infection
5. Chronic fatigue syndrome
6. Coeliac disease
7. Domestic abuse, inc. child abuse
8. Drugs
9. Faecal impaction
10. Foreign bodies
11. Giardiasis
12. Haemochromatosis
13. Herpes zoster
14. Lead poisoning
15. Menopause syndrome
16. Migraine (atypical variants)
17. Paget disease
18. Pregnancy (early)
19. Seizure disorders
20. Urinary infection

Masquerades

Primary – D₃ATSU

1. Depression
2. Diabetes mellitus
3. Drugs
   • iatrogenic
   • self-abuse
   • alcohol
   • narcotics
   • nicotine
   • others
4. Anaemia
5. Thyroid and other endocrine disorders
   • hyperthyroidism
   • hypothyroidism
   • Addison disease
6. Spinal dysfunction
7. Urinary infection

Secondary – C₃ABBN

1. CKD
2. Cancer
   • lymphomas/leukaemias
   • lung
   • caecum/colon
   • kidney
   • multiple myeloma
   • ovary
   • metastasis
3. Connective tissue disorders and the vasculitides
   • Connective tissue disorders
     • SLE
     • systemic sclerosis
     • dermatomyositis
     • overlap syndrome
   • Vasculitides
     • polyarteritis nodosa
     • giant cell arteritis/polymyalgia rheumatica
     • granulomatous disorders and others
4. AIDS/HIV infection
5. Baffling viral (and protozoal) infections
   • Epstein-Barr mononucleosis
   • TORCH organisms
     • Toxoplasmosis.
     • Other (such as syphilis, varicella, mumps, parvovirus, and HIV)
     • Rubella.
     • Cytomegalovirus.
     • Herpes simplex and Hep B
   • Hepatitis A, B, C, D, E, F, G
   • mosquito-borne infections
   • malaria
   • Ross River fever
   • dengue
   • others
6. Baffling bacterial infections
   • syphilis
   • tuberculosis
   • infective endocarditis
   • the zoonoses
   • Chlamydia infections
   • atypical pneumonias
   • others
7. Neurological dilemmas
   • Parkinson disease
   • Guillain–Barre syndrome
   • seizure disorders esp., complex partial
   • multiple sclerosis
   • myasthenia gravis
   • space-occupying lesion of the skull
   • migraine and its variants
   • others

Patient Thinks

• Is this Patient trying to Tell me something else?