Family medicine
Abdominal Swelling / Distension
Abdominal swelling or distension is an increase in abdominal girth caused by conditions such as ascites, organomegaly, bowel obstruction, intra-abdominal masses, or excessive gas accumulation.
Murtagh Diagnostic Strategy
6 F's of abdominal distension: Fat, Fluid (ascites), Foetus, Flatus (bowel obstruction), Faeces, Full-sized tumour (+ Full bladder) [1][3][4]
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Ascites secondary to liver cirrhosis (esp. HBV/alcohol in HK) [1] | Chronic alcohol/HBV + shifting dullness + stigmata of CLD | 「你有冇乙肝或者飲酒習慣？」; shifting dullness on percussion |
| Functional bloating / IBS | Intermittent, related to meals, no weight loss, normal exam | 「食完嘢會唔會特別脹？有冇時好時壞？」 | |
| Serious Not To Miss | Intra-abdominal malignancy (ovarian CA, colorectal CA, gastric CA, HCC) | Progressive distension + weight loss + hard irregular mass / bloody ascites | 「體重有冇輕咗？大便有冇血？」; hard irregular hepatomegaly or pelvic mass |
| Intestinal obstruction | Absolute constipation + colicky pain + vomiting + high-pitched bowel sounds | 「有冇完全去唔到大便同放唔到屁？有冇嘔？」; tinkling bowel sounds | |
| Ruptured ectopic pregnancy (female of reproductive age) | Acute onset + missed period + haemodynamic instability | 「月經有冇遲咗？有冇突然好痛？」 | |
| Pitfalls | Ovarian cyst / tumour | Pelvic fullness, urinary frequency; umbilicus points upward [3] | 「有冇覺得下腹脹、成日想去廁所？」; suprapubic mass, can't get below it |
| Chronic constipation / faecal loading | Elderly, opioid use, palpable faeces in LIF | 「幾耐去一次大便？食緊止痛藥嗎？」; palpable indentable mass LIF | |
| Nephrotic syndrome | Generalised oedema + frothy urine + hypoalbuminaemia | 「小便有冇好多泡？」; periorbital + pedal oedema | |
| TB peritonitis | Immigrant/immunocompromised + fever + weight loss + exudative ascites | 「有冇發燒、夜晚出汗？有冇接觸過肺癆病人？」 | |
| Masquerades | Heart failure (R-sided → ascites + ankle oedema) | Orthopnoea, PND, raised JVP, ankle oedema [5] | 「瞓低會唔會氣喘？要墊幾多個枕頭？」; elevated JVP, bilateral pitting oedema |
| Hypothyroidism (myxoedema → ileus) | Cold intolerance, weight gain, constipation | 「有冇怕凍、成日攰、便秘？」 | |
| Drugs (opioids → ileus; steroids → obesity) | Temporal relationship with medication | 「最近有冇轉藥或者加藥？」 | |
| Trying to Tell Me Something? | Fear of cancer; family member recently diagnosed with cancer; depression; domestic stress | Patient anxious, vague complaints, frequent visits | 「你最擔心係咩？屋企最近有冇咩事發生？」 |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, set agenda | 「你好，我係X醫生，今日想同你傾下你嘅情況。可唔可以叫你做X先生/小姐？今日嚟睇醫生最主要想解決咩問題呀？」 | Friendly opening + patient-centred; marks for interpersonal skills |
| 0:30–1:30 | HPI – symptom analysis | 「個肚幾時開始脹㗎？係慢慢脹大定突然間脹嘅？有冇越嚟越嚴重？有冇肚痛、嘔、去唔到大便？體重有冇變？」 | Core history; establishes timeline, severity, associated symptoms |
| 1:30–2:30 | Red flags + systems review | 「有冇發燒？有冇痾血或者便便變黑色？有冇皮膚或者眼白變黃？食嘢有冇冇胃口或者食少少就飽？腳有冇腫？有冇氣喘？」 | Red flags for malignancy, GI bleed, liver failure, heart failure, obstruction |
| 2:30–3:15 | PMH, drugs, allergy, FHx, social hx | 「之前有冇乜嘢長期病？有冇食緊乜嘢藥？有冇藥物敏感？屋企人有冇肝病或者癌症？你平時飲唔飲酒？飲幾多？食唔食煙？」 | Alcohol/hepatitis B are #1 causes of cirrhosis in HK; drug hx critical |
| 3:15–4:00 | ICE – Ideas, Concerns, Expectations | 「你自己覺得個肚脹係咩原因呢？(Ideas) 你最擔心啲咩嘢？(Concerns) 你今日最希望醫生可以幫到你啲咩？(Expectations)」 | Direct marks for ICE; uncovers hidden agenda |
| 4:00–4:45 | Uncover hidden agenda / functional impact | 「呢個問題有冇影響到你返工或者瞓覺？有冇影響到你嘅心情？屋企人有冇擔心？有冇其他嘢你想同我講嘅？」 | "Why today?" may reveal fear of cancer, family pressure, functional decline |
| 4:45–5:30 | Signpost → brief targeted exam mention + summarise | 「咁我總結下：你個肚脹咗X個星期，仲有XX。我想幫你檢查下個肚，特別想聽下、篤下。」 | Summarising scores interpersonal marks; shows you listened |
| 5:30–6:00 | Empathy, safety-net, close | 「我明白你好擔心，我哋會幫你搵清楚原因。如果有咩突然肚痛好犀利、嘔血或者個肚越嚟越脹，記住即刻去急症室。」 | Safety-net = must-have for FM; empathy line scores |
Uncovering the Hidden Agenda
Ask 「點解揀今日嚟呀？」 (Why did you come today specifically?) — often the patient came because a relative noticed the swelling, or they fear cancer / liver disease. This is frequently the ONE main reason for consultation, not just "abdominal swelling."
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset / Duration | When did you first notice the swelling? Gradual or sudden? | 「幾時開始發覺個肚脹㗎？慢慢脹定突然間脹？」 | Acute → obstruction, bleed; chronic → cirrhosis, malignancy | Acute: obstruction. Weeks–months: ascites, tumour |
| Progression | Is it getting bigger? | 「有冇越嚟越大？」 | Progressive = serious pathology | Cirrhosis (decompensating), ovarian mass, malignancy |
| Associated pain | Any abdominal pain? Where? | 「有冇肚痛？邊度痛？」 | Pain localisation narrows DDx | Diffuse + distension → obstruction/peritonitis; RUQ → liver |
| Bowel habit | Any change in bowel habits? Constipation? Blood/mucus? | 「大便有冇唔同咗？有冇便秘？有冇血或者黐液？」 | Obstruction, colorectal CA | Alternating habit + blood → colorectal CA; absolute constipation → obstruction |
| Vomiting | Any vomiting? What colour? | 「有冇嘔？嘔出嚟咩色？」 | Bilious → distal obstruction; feculent → late obstruction | High obstruction: early vomiting. Low: late/feculent |
| Weight loss / appetite | Any weight loss? Appetite change? | 「體重有冇輕咗？食嘢有冇胃口？」 | Constitutional → malignancy, TB, cirrhosis | Cancer, TB peritonitis, decompensated CLD |
| Jaundice | Have your eyes/skin turned yellow? | 「眼白或者皮膚有冇變黃？」 | Liver disease, biliary obstruction | Cirrhosis, pancreatic head CA, hepatitis |
| Ankle swelling / SOB | Any leg swelling or breathlessness? | 「腳有冇腫？有冇氣喘或者瞓低氣喘？」 | R heart failure → hepatic congestion + ascites; nephrotic | CHF, nephrotic syndrome, cirrhosis |
| Alcohol history | Do you drink? How much per week? For how long? | 「你飲唔飲酒㗎？一個禮拜飲幾多？飲咗幾多年？」 | Alcohol is a major cause of cirrhosis in HK [1] | Alcoholic liver disease / cirrhosis |
| Hepatitis B/C | Have you been tested for Hep B? Are you a carrier? | 「你有冇驗過乙型肝炎？你係唔係帶菌者？」 | HBV is the #1 cause of cirrhosis/HCC in HK [1] | Chronic HBV → cirrhosis → ascites/HCC |
| Drug history | Any medications? NSAIDs? TCM? | 「有冇食緊咩藥？有冇食止痛藥或者中藥？」 | Hepatotoxic drugs, NSAIDs → GI bleed | Drug-induced liver injury |
| Gynae/menstrual (if female) | When was your last period? Could you be pregnant? | 「你最後一次月經幾時？有冇可能懷孕？」 | Pregnancy, ovarian cyst/tumour, fibroid | Foetus, ovarian mass, uterine fibroid [2] |
| Family history | Any family history of liver disease or cancer? | 「屋企人有冇肝病或者癌症？」 | HBV vertical transmission, familial CRC | HBV carrier family, Lynch syndrome |
| Functional impact | Does this affect your work/daily life/sleep? | 「有冇影響到你返工、日常生活或者瞓覺？」 | Scores biopsychosocial marks | Social/functional problem for CRF |
| Mood | How is your mood? Any worries? | 「你心情點呀？有冇擔心或者唔開心？」 | Depression, anxiety re diagnosis | Psychological problem for CRF |
Case Report Form Answer Builder
- CC format: "Abdominal swelling/distension for [duration]"
- HPI must capture: onset (acute vs gradual), progression, associated symptoms (pain, vomiting, change in bowel habit, weight loss, jaundice, ankle swelling, SOB), aggravating/relieving factors
- Include relevant background: alcohol intake, HBV status, drug history, menstrual/obstetric history if female
Examples:
- "Patient noticed progressively enlarging abdomen over 2 months and is worried about liver disease"
- "Wife noticed the swelling and urged patient to seek medical attention" ← hidden agenda
- "Patient concerned about cancer because a relative was recently diagnosed"
- Phrase as the patient's own reason, not a medical diagnosis
| Likely Examples | Exact Wording for CRF | |
|---|---|---|
| Ideas | "I think it might be fluid / my liver / cancer" | "Patient thinks the swelling may be due to liver problems / water retention" |
| Concerns | "I'm worried it could be cancer" / "worried about ability to work" | "Patient is worried the swelling might be cancer / worried about impact on livelihood" |
| Expectations | "I want a scan" / "I want to know if it's serious" | "Patient hopes for an ultrasound to find out the cause / wants reassurance" |
- In a middle-aged/elderly HK male with alcohol or HBV history → Ascites secondary to liver cirrhosis [1]
- Minimum supporting evidence: gradual distension + shifting dullness + risk factor (HBV carrier / alcohol) ± stigmata of CLD (spider naevi, palmar erythema, jaundice)
- In a female → consider ovarian mass / pregnancy depending on age and context
| DDx | Key Discriminator |
|---|---|
| 1. Intra-abdominal malignancy (e.g. ovarian CA, colorectal CA with peritoneal carcinomatosis) | Weight loss + hard mass + bloody/exudative ascites (SAAG < 1.1) |
| 2. Congestive heart failure (R-sided) | Orthopnoea, PND, elevated JVP, bilateral ankle oedema |
| 3. Intestinal obstruction | Colicky pain + absolute constipation + vomiting + tinkling bowel sounds |
| Domain | Problem |
|---|---|
| Biological | Underlying liver cirrhosis with risk of decompensation (variceal bleed, SBP, HE) |
| Psychological | Anxiety / fear of cancer diagnosis; low mood due to chronic illness and uncertainty |
| Social | Functional impairment affecting work / ADLs; financial burden; if alcoholic → need for social support for abstinence |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Ascites (cirrhosis) [1] | Shifting dullness | Patient supine → percuss from umbilicus laterally until dull → mark → turn patient to opposite side → re-percuss; dull → resonant = positive | Demonstrates free intra-peritoneal fluid; most reliable bedside sign for ascites [1][3] |
| Ascites (cirrhosis) – additional | Fluid thrill | Assistant places edge of hand on midline; flick one flank, feel impulse on other | Confirms large-volume ascites ( > 1L) |
| Intra-abdominal malignancy | Hard, irregular hepatomegaly or palpable pelvic mass | Palpate RUQ on inspiration; bimanual pelvic palpation | Hard craggy liver edge → HCC/mets; fixed pelvic mass → ovarian CA |
| Congestive heart failure | Elevated JVP with hepatojugular reflux | 45° head-up; compress liver for 15 s → sustained JVP rise ≥ 3 cm | Proves R heart pressure overload causing hepatic congestion and ascites [5] |
| Intestinal obstruction | High-pitched tinkling bowel sounds | Auscultate near umbilicus for ≥ 2 min | Hyperactive, tinkling quality pathognomonic of mechanical obstruction [3] |
| Ovarian mass | Suprapubic mass – cannot get below it; umbilicus points upward [3] | Palpate suprapubic area; note relationship to pubic symphysis | Pelvic origin mass rises out of pelvis; dull to percussion; distinct from ascites |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to ask about HBV status – Hong Kong-specific; HBV is the #1 cause of cirrhosis/HCC here [1].
- Not asking about pregnancy in any female of reproductive age — Foetus is one of the 6 F's [3][4].
- Confusing ascites with ovarian cyst — Ascites: flanks bulge, umbilicus horizontal/everted, shifting dullness positive. Ovarian cyst: suprapubic mass, umbilicus points upward, NO shifting dullness [3].
- Writing the diagnosis as the "main reason for consultation" — RFC should be in the patient's own words/perspective, not a medical label.
- Omitting ICE entirely — these are separately marked; must elicit all three.
- Not safety-netting — always give red-flag advice at the end of the consultation.
| Red Flag | Concern | Action |
|---|---|---|
| Rapid-onset tense ascites + fever + abdominal tenderness | SBP or perforation | Same-day A&E referral |
| Haematemesis / melaena | Variceal bleed / UGIB | Emergency A&E |
| New-onset jaundice + confusion | Decompensated liver failure / HE | Urgent admission |
| Absolute constipation + vomiting + distension | Intestinal obstruction | Surgical emergency referral |
| Acute severe abdominal pain + haemodynamic instability (female) | Ruptured ectopic pregnancy | Emergency resuscitation + referral |
| Progressive weight loss + hard mass | Malignancy | Urgent outpatient referral for imaging + biopsy |
「如果個肚突然好痛、嘔血、大便變黑色、或者發燒唔退，要即刻去急症室。我哋會安排驗血同照超聲波幫你搵原因。」
High Yield Summary
What to ASK: HBV status, alcohol, onset/progression of swelling, weight loss, bowel habit, jaundice, ankle oedema, SOB, menstrual/pregnancy history (females), ICE, and "Why today?"
What to WRITE on CRF: CC with duration → HPI chronologically → RFC in patient's words → ICE separately → Most likely Dx with evidence → 3 DDx with discriminators → 3 biopsychosocial problems → Physical sign = shifting dullness for ascites
What NOT to MISS: HBV, pregnancy, intestinal obstruction, malignancy. Safety-net red flags. ICE must be explicitly elicited and documented.
6 F's of abdominal distension: Fat, Fluid, Foetus, Flatus, Faeces, Full-sized tumours [1][3][4] — this is the core framework examiners expect.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 026. Abdominal distension_ascites and cirrhosis.pdf; Senior notes: Block A - Abdominal distension_ ascites and cirrhosis.pdf [2] Lecture slides: GC 118. Pelvic mass ovarian cancer and cysts; uterine fibroid; pelvic imaging.pdf; Block C - Pelvic mass_ ovarian cancer and cysts; uterine fibroid; pelvic imaging.pdf [3] Lecture slides: CFB (MED07) Examination of the Abdomen.pdf; abdominal exam (MBBS IV) (student version).pdf; Clinical Demonstration_Abdomen.pdf; Senior notes: Ryan Ho Fundamentals.pdf (p.68); Ryan Ho GI.pdf (p.16, p.28) [4] Senior notes: Maksim Surgery Notes.pdf (p.44 — Ascites causes, 5F's/6F's) [5] Senior notes: Ryan Ho Fundamentals.pdf (p.216 — Heart failure S/S); MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.540); Maksim Medicine Notes.pdf (p.137)
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