Family medicine
Arthralgia / Arthritis
Arthralgia refers to joint pain without inflammation, whereas arthritis denotes joint inflammation characterized by pain, swelling, warmth, and restricted range of motion.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Osteoarthritis | Older age, DIP/weight-bearing joints, mechanical pain, < 30 min morning stiffness, crepitus on examination [1][4] | 「個膝頭係咪行多啲就痛啲，休息就好返？」(Is the knee worse with activity, better with rest?) |
| Gout | Acute onset, 1st MTP, intense pain/redness, self-limiting, may have fever [1][3] | 「係咪腳趾公突然好痛好紅腫？」(Sudden severe pain/redness at big toe?) | |
| Rheumatoid arthritis | Symmetrical polyarthritis, MCP/PIP/wrist, spares DIP, morning stiffness ≥30 min, RF/anti-CCP +ve [1][3] | 「兩隻手嘅手指關節係咪兩邊都腫？朝早僵硬超過半個鐘？」 | |
| Serious Not To Miss | Septic arthritis | Hot swollen tender monoarthritis ± fever = septic until proven otherwise [5][6] | 「個關節係咪好熱好腫，加埋發燒？」 |
| SLE arthritis | Young female, malar rash, photosensitivity, oral ulcers, hair loss, multi-system [2] | 「有冇面紅疹、甩頭髮、口腔潰瘍？」 | |
| Malignancy / paraneoplastic | Unexplained weight loss, night sweats, bone pain, new onset in elderly | 「有冇唔見輕咗？夜晚出好多汗？」 | |
| Pitfalls | Pseudogout (CPPD) | Elderly female, knee (most common), mimics gout; confirmed by weakly +ve birefringent crystals [2] | 「你膝頭有冇突然紅腫痛？」 |
| Psoriatic arthritis | Psoriasis (may be hidden – scalp, nails, natal cleft), asymmetric, DIP, dactylitis, nail pitting [1] | 「有冇皮膚銀屑病？指甲有冇凹凹窿窿？」 | |
| Reactive arthritis | Recent GI/GU infection, asymmetric oligoarthritis, conjunctivitis, urethritis [1] | 「最近有冇肚瀉或者泌尿道感染？」 | |
| Masquerades | Depression | Chronic pain → low mood, poor sleep, loss of interest; or somatisation | 「你心情點呀？有冇瞓得差？」 |
| Hypothyroidism | Arthralgia + fatigue + weight gain + constipation | 「有冇成日覺得攰、肥咗、便秘？」 | |
| Drug-induced | Diuretics → gout; quinolones → tendinopathy; statins → myalgia | 「有冇食去水丸或者降膽固醇藥？」 | |
| Trying to Tell Me Something? | Psychosocial stress / fear of disability | Fear of wheelchair, job loss; hidden agenda: read about RA online | 「你最擔心啲乜嘢？擔唔擔心會行唔到？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, intro, rapport | 「你好呀！我係X醫生，今日由我同你傾吓。請問點稱呼你呀？」 (Hello! I'm Dr X, I'll be seeing you today. How should I address you?) | Friendly opening scores interpersonal marks. Use patient's name throughout. |
| 0:30–1:30 | Open-ended HPI – let patient tell their story, then clarify onset/duration/site/pattern/severity/aggravating-relieving | 「可唔可以話畀我聽吓邊度唔舒服呀？」→「痛咗幾耐？」→「係幾時開始嘅？」→「係一個關節定係幾個關節痛呀？」→「邊個關節呀？」→「朝早起身有冇覺得啲關節好僵硬？大概僵硬幾耐？」 | Captures chief complaint, onset, joint count/pattern, morning stiffness duration (key inflammatory vs degenerative discriminator [1]). |
| 1:30–2:30 | Symptom analysis + red flags – inflammatory features, systemic sx, functional impact | 「個關節有冇紅、腫、熱呀？」→「有冇發燒呀？」→「有冇唔見輕咗？」→「有冇眼紅或者出皮疹？」→「有冇影響到你返工或者日常生活呀？」 | Screens for septic arthritis (fever + hot joint), systemic features of SLE/SpA; functional impact = social domain. |
| 2:30–3:30 | Targeted Hx – PMHx, DHx, FHx, social, sexual/menstrual if relevant | 「你以前有冇其他病，例如糖尿、痛風、牛皮癬、腸炎？」→「而家食緊咩藥？有冇藥物敏感？」→「屋企人有冇類似嘅關節問題？」→「你做邊行㗎？」→「有冇飲酒嘅習慣？」 | PMHx (psoriasis/IBD → SpA); DHx (diuretics → gout); FHx (RA/SpA); occupation (overuse → OA); alcohol (gout trigger). |
| 3:30–4:30 | ICE – Ideas, Concerns, Expectations | 「你自己覺得呢個痛可能係咩嚟㗎？」(Ideas) →「你最擔心啲乜嘢？」(Concerns) →「今日嚟睇，你最希望我幫到你啲咩？」(Expectations) | ICE is a discrete scored field. Must elicit all three with separate questions. Hidden agenda often emerges here. |
| 4:30–5:15 | Uncover hidden agenda + signpost | 「除咗關節痛之外，仲有冇其他嘢令你煩惱或者擔心㗎？」→「我嚟總結一下你今日嘅情況…」 | The real RFC may be fear of disability/cancer, mood issues, or work impact. Signposting shows structure. |
| 5:15–6:00 | Summarise, check understanding, close | 「等我同你覆述一下…有冇邊度我講漏咗？」→「我嘅初步計劃係…如果有咩新嘅症狀，例如突然腫一個關節加發燒，一定要即刻嚟睇返呀。」→「你仲有冇問題想問？多謝你！」 | Summarise = accuracy check. Safety-net (septic arthritis red flag) is critical. Polite close. |
Uncovering the hidden agenda: Ask 「點解你揀今日嚟睇呀？」(Why did you choose to come today?) — the trigger (e.g. couldn't open a jar, boss complained, read about lupus online) reveals the true RFC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/duration | When did joint pain start? Acute or gradual? | 「幾時開始痛㗎？係突然痛定慢慢嚟㗎？」 | Acute → gout/septic; insidious → RA/OA [1] | Acute: gout, septic; Chronic ≥6 wk: RA, SpA, OA |
| Number & pattern | How many joints? Symmetrical? | 「痛幾多個關節呀？兩邊對稱定淨係一邊？」 | Mono vs oligo vs polyarthritis is the first branch point [1][2] | Mono: gout/septic; Sym poly: RA; Asym oligo: SpA |
| Which joints | Which joints exactly? | 「邊啲關節呀？手指、膝頭、腳趾？」 | RA: MCP/PIP/wrist, spares DIP; OA: DIP/weight-bearing; Gout: 1st MTP [1][3] | Site is a key discriminator |
| Morning stiffness | Morning stiffness? How long? | 「朝早起身啲關節有冇僵硬？大概僵硬幾耐先鬆返？」 | ≥30 min → inflammatory; < 30 min → degenerative [1][4] | ≥30 min: RA/SpA; < 30 min: OA |
| Aggravating/relieving | Worse with rest or activity? | 「係做嘢痛啲定係休息時痛啲？」 | Inflammatory: worse at rest, better with movement; Degenerative: worse with use, better with rest [1][4] | Inflammatory vs mechanical |
| Swelling/redness/warmth | Any redness, swelling, warmth? | 「個關節有冇紅腫或者覺得發熱？」 | Synovitis = inflammatory arthritis [2] | Septic, gout, RA flare |
| Fever | Any fever? | 「有冇發燒呀？」 | Hot swollen joint + fever = septic arthritis until proven otherwise [5][6] | Septic arthritis — URGENT |
| Skin | Any rash, psoriasis, nodules? | 「身上有冇出皮疹、銀屑病或者粒嘢？」 | Psoriasis → PsA; malar rash → SLE; tophi → gout [1][2] | SpA, SLE, gout |
| Eyes | Any red eyes or blurred vision? | 「有冇眼紅或者睇嘢矇咗？」 | Uveitis → SpA/JIA; keratoconjunctivitis → Sjögren's [2] | SpA, SLE, Sjögren's |
| Back pain | Any low back pain or stiffness? | 「有冇腰骨痛或者腰僵硬呀？」 | Inflammatory back pain → axial SpA/AS [1] | Ankylosing spondylitis |
| GI/GU | Any diarrhoea, bloody stool, urethral discharge? | 「有冇肚瀉、大便有血、或者尿道有分泌物？」 | IBD → IBD-SpA; urethritis/dysentery → reactive arthritis [1] | Reactive arthritis, IBD-SpA |
| PMHx | DM, gout, renal disease, psoriasis, IBD? | 「有冇糖尿、痛風、腎病、牛皮癬或者腸炎？」 | Comorbidities guide DDx | Secondary gout (CKD), PsA |
| Drug Hx | Current medications? Diuretics? NSAIDs? | 「而家有冇食藥？有冇食去水丸或者止痛藥？」 | Diuretics/aspirin ↑urate → gout; NSAIDs → GI bleeding in RA patients [7] | Drug-induced hyperuricaemia |
| Allergy | Drug allergy? | 「有冇藥物敏感？」 | Safety; required field | — |
| FHx | Family history of joint disease or autoimmune? | 「屋企人有冇關節炎或者自身免疫病？」 | RA, SpA, gout have familial tendency [1] | RA, AS, gout |
| Social/occupation | Job? Hobbies? Alcohol? | 「你做邊行㗎？有冇飲酒習慣？」 | Occupational overuse → OA; alcohol/seafood → gout; functional impact | OA, gout |
| Functional impact | Impact on daily life, work, mood? | 「關節痛有冇影響到你返工、瞓覺或者心情？」 | Captures psychosocial domain for case report | Biopsychosocial problems |
| Sexual Hx (if young adult) | New sexual partner? STI symptoms? | 「最近有冇新嘅性伴侶？有冇尿道唔舒服？」 | Disseminated gonococcal infection; reactive arthritis [5] | Gonococcal arthritis, reactive arthritis |
Case Report Form Answer Builder
Write: "Joint pain at [site] for [duration]" then cover:
- Onset (acute vs insidious), duration, number of joints (mono/oligo/poly), pattern (symmetrical?), specific joints
- Character of pain, severity (0–10), aggravating/relieving factors
- Morning stiffness duration (≥30 min = inflammatory) [1]
- Swelling/redness/warmth, systemic symptoms (fever, weight loss, fatigue)
- Extra-articular features: skin rash, eye sx, back pain, GI/GU sx
- PMHx, DHx (esp diuretics, NSAIDs), FHx, functional impact
| Scenario | Best RFC Phrasing |
|---|---|
| Worried about RA after reading online | "Patient seeks assessment and diagnosis of joint pain due to concern about rheumatoid arthritis" |
| Pain affecting work | "Patient seeks pain relief as joint pain affecting ability to work" |
| Acute flare | "Patient seeks urgent management of acutely swollen painful joint" |
| Chronic joint pain | "Patient seeks investigation and management of chronic joint pain" |
Tip: The RFC must be a single sentence reflecting WHY the patient came TODAY, not just the symptom.
| Component | Example Phrasing |
|---|---|
| Ideas | "Patient thinks she may have rheumatoid arthritis because her mother had it" |
| Concerns | "Patient is worried about becoming disabled and unable to work" |
| Expectations | "Patient expects blood tests and medication to control joint pain" |
Choose based on the stem's clues:
| Stem Clue | Most Likely Dx | Minimum Evidence |
|---|---|---|
| Older patient, knee/hip pain worse with activity, < 30 min stiffness | Osteoarthritis | Age, weight-bearing joint, mechanical pain, crepitus |
| Young/middle-aged, symmetrical small joint polyarthritis, morning stiffness ≥30 min | Rheumatoid arthritis | Symmetrical MCP/PIP, prolonged morning stiffness, RF/anti-CCP |
| Acute 1st MTP monoarthritis, severe pain, redness | Gout | 1st MTP, acute onset, podagra |
| Acute monoarthritis + fever + hot joint | Septic arthritis | Fever, monoarthritis, risk factors |
| If Most Likely = OA | DDx | Key Discriminator |
|---|---|---|
| 1 | Gout | Acute onset, crystal-proven, 1st MTP |
| 2 | Rheumatoid arthritis | Symmetrical small joints, prolonged MS, RF +ve |
| 3 | Pseudogout (CPPD) | Elderly, knee, chondrocalcinosis on XR |
| If Most Likely = RA | DDx | Key Discriminator |
|---|---|---|
| 1 | SLE arthritis | Young female, multi-system, non-erosive, ANA +ve |
| 2 | Psoriatic arthritis | Asymmetric, DIP involvement, psoriasis, nail changes |
| 3 | Viral polyarthritis | Self-limiting < 6 wk, prodromal illness, exposure Hx |
| If Most Likely = Gout | DDx | Key Discriminator |
|---|---|---|
| 1 | Septic arthritis | Fever, systemically unwell, need joint aspirate |
| 2 | Pseudogout | Knee > foot, elderly female, CPPD crystals |
| 3 | Reactive arthritis | Recent GI/GU infection, oligoarthritis |
| Domain | Example |
|---|---|
| Biological | "Uncontrolled joint inflammation causing pain and swelling" OR "Risk of joint destruction if RA untreated" |
| Psychological | "Anxiety about diagnosis and fear of disability" OR "Low mood secondary to chronic pain" |
| Social/Functional | "Unable to perform job duties (e.g. typing, manual labour)" OR "Reduced ability to care for children/elderly parents" |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Dx |
|---|---|---|---|
| Osteoarthritis | Crepitus on passive ROM + bony enlargement (Heberden's/Bouchard's nodes) | Palpate joint while passively flexing/extending knee or hand joints | Crepitus = cartilage loss; bony nodes = osteophyte formation, pathognomonic of OA [4][8] |
| Rheumatoid arthritis | Symmetrical MCP/PIP joint swelling (boggy synovitis) with tenderness | Bimanual squeeze test of MCPs; palpate for warmth and soft tissue swelling | Boggy synovial thickening at MCP/PIP bilaterally = active RA synovitis [1][3] |
| Gout | Gouty tophi at ear helix, 1st MTP, olecranon; or acutely hot, red, exquisitely tender 1st MTP | Inspect and palpate; tophi are firm, yellowish subcutaneous nodules [2] | Tophi = MSU crystal deposits, pathognomonic of chronic tophaceous gout |
| Septic arthritis | Hot, swollen, extremely tender joint with severely restricted ROM in ALL directions | Attempt passive ROM — patient resists due to pain; joint held in flexion | Exquisite tenderness + severely restricted ROM = high suspicion; joint aspiration is diagnostic [5][6] |
| SLE | Malar (butterfly) rash | Inspect face; rash spares nasolabial folds, non-scarring | Highly specific for SLE; supports SLE as cause of arthritis |
| Psoriatic arthritis | Nail pitting or onycholysis + dactylitis (sausage digit) | Inspect all fingernails and toes; palpate swollen digits | Nail changes present in ~80% PsA; dactylitis is characteristic of PsA [1] |
| Pseudogout | No reliable bedside sign to distinguish from gout in FM station | Best clue: elderly female + knee involvement; confirmed by joint aspirate showing weakly +ve birefringent rhomboid crystals | Diagnosis is aspirate-dependent; XR may show chondrocalcinosis |
Top Traps That Lose Marks
- Forgetting to ask morning stiffness DURATION — this is THE discriminator between inflammatory (≥30 min) and degenerative (< 30 min) [1]. Examiners actively look for this.
- Not asking about fever in acute monoarthritis — missing septic arthritis is an exam fail. A hot, swollen, tender joint = septic arthritis until proven otherwise, even without fever or ↑WBC [5][6].
- Writing "joint pain" as RFC — RFC must explain WHY the patient came TODAY, not the symptom itself.
- Confusing RA and OA joint distribution — RA spares DIP; OA affects DIP and weight-bearing joints [1][3].
- Forgetting ICE — each component (Ideas, Concerns, Expectations) is a separately scored field. Ask three separate questions.
- Not screening for extra-articular features — psoriasis, uveitis, oral ulcers, rash, back pain, GI/GU sx are all needed to differentiate SpA, SLE, and reactive arthritis.
- Skipping social/functional impact — you need this for the biopsychosocial problem (social domain).
Must-Not-Miss Red Flags — Urgent Referral:
- Acute monoarthritis + fever → suspect septic arthritis → urgent ED referral for joint aspiration [5][6]
- New joint symptoms + malar rash + proteinuria → suspect SLE with renal involvement → urgent rheumatology
- Acute monoarthritis + anticoagulation/haemophilia → suspect haemarthrosis → urgent orthopaedics
- Joint pain + unexplained weight loss + bone pain in elderly → suspect malignancy → urgent workup
Shortest Safe Management/Safety-Net Line:
「如果你個關節突然好紅好腫加埋發燒，一定要即刻去急症室，因為可能係感染，要盡快處理。」 (If your joint suddenly becomes very red, swollen, and you have fever, go to A&E immediately — it may be an infection needing urgent treatment.)
High Yield Summary
What to ASK: Onset/duration, number & distribution of joints, morning stiffness duration (THE discriminator), swelling/redness/warmth, fever, skin (psoriasis/rash), eyes, back pain, GI/GU sx, PMHx/DHx (diuretics!)/FHx, occupation, functional impact, ICE, hidden agenda.
What to WRITE on the Case Report Form:
- CC: "[Joint] pain for [duration]"
- RFC: Why today — not just the symptom
- ICE: Three separate components with specific patient wording
- Dx: Use joint pattern + morning stiffness + age + extra-articular features to pick ONE most likely
- DDx: Three alternatives with one-line discriminator each
- BPS: One biological (disease/complication), one psychological (fear/mood), one social (work/ADL)
- Physical sign: Match to your most likely Dx (see table above)
What NOT to MISS: Septic arthritis (hot joint + fever = emergency), SLE multi-system, malignancy in elderly, and always differentiate inflammatory vs degenerative.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 074. Multiple joint pain.pdf (Clinical features of different arthritis — history) [2] Senior notes: Ryan Ho Rheumatology.pdf (Ch 2.2 Approach to Polyarthritis) [3] Senior notes: Block A - Multiple joint pain_ Rheumatoid arthritis and the concept of inflammatory arthritis.pdf [4] Senior notes: Maksim Surgery Notes.pdf (9.1 Osteoarthritis — Degenerative vs inflammatory table) [5] Senior notes: Adrian Lui Pediatrics Notes.pdf (13.2.4 Septic Arthritis) [6] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (Septic arthritis clinical features) [7] Senior notes: Block A - Hematology Interactive Tutorial.pdf (RA patient with anaemia — drug history) [8] Senior notes: Maksim Medicine Notes.pdf (13.1 Clinical approach — Joint pain)
Amenorrhoea
Amenorrhoea is the absence or abnormal cessation of menstruation, classified as primary (failure to menstruate by age 15) or secondary (cessation of previously established menses for three or more months).
Back Pain (lower)
Lower back pain is a common musculoskeletal condition characterized by pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without radiating leg pain.