Most Common HK Primary Care Symptoms
Diarrhoea
Diarrhoea is the passage of three or more loose or watery stools per day, or more frequently than is normal for the individual, resulting from increased intestinal secretion, decreased absorption, or altered motility.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Acute viral gastroenteritis (norovirus, rotavirus) | Acute onset, vomiting prominent, watery, self-limiting, contact Hx | 「屋企或者公司有冇其他人一齊肚痾嘔？」(Anyone else sick at home/work?) | ~35% |
| Food poisoning (bacterial) | Acute, epidemiological link to food, incubation period | 「喺邊度食嘢之後開始痾？食完幾耐先開始？」(Where did you eat? How soon after?) | ~20% | |
| IBS (if chronic) | Chronic, relapsing, pain relieved by defecation, no red flags, no nocturnal symptoms [2] | 「去完廁所之後肚痛會唔會好啲？半夜有冇痾醒？」(Pain better after stool? Wake at night?) | ~15% | |
| Serious Not To Miss | C. difficile colitis | Recent antibiotics, hospital exposure, profuse watery/bloody diarrhoea | 「最近兩個月有冇食過抗生素或者入過醫院？」(Antibiotics or hospitalisation recently?) | ~2% |
| Severe dehydration / sepsis | Hypotension, tachycardia, oliguria, altered consciousness | Check vitals, skin turgor, mucous membranes | ~2% | |
| IBD (Crohn's / UC) | Chronic bloody diarrhoea, mucus, extraintestinal features, young adult, fecal calprotectin elevated [6] | 「有冇口腔潰瘍、關節痛、或者眼紅？」(Oral ulcers, joint pain, red eye?) | ~1% | |
| Colorectal carcinoma | Age > 50, weight loss, rectal bleeding, change in bowel habit, iron-deficiency anaemia | 「大便有冇血？體重有冇輕咗？」(Blood in stool? Weight loss?) | ~1% | |
| Pitfalls | Lactose intolerance | Diarrhoea after dairy, bloating, very common in Asians [3] | 「飲完牛奶會唔會肚脹痾肚？」(Bloating/diarrhoea after milk?) | ~10% |
| Overflow diarrhoea (faecal impaction) | Elderly, paradoxical diarrhoea, constipation Hx | 「之前有冇便秘呀？」(Any prior constipation?) DRE for faecal loading | ~3% | |
| Coeliac disease | Steatorrhoea, weight loss, iron/folate deficiency (less common in HK but testable) | 「大便有冇好油好臭、浮喺水面？」(Greasy stools that float?) | < 1% | |
| Masquerades | Drug-induced diarrhoea | Temporal link to medication (metformin, Mg-antacid, PPI, antibiotics, colchicine) [1] | 「食咗新藥之後幾時開始痾？」(When did diarrhoea start relative to new medication?) | ~10% |
| Depression | Low mood, altered appetite, functional GI symptoms | 「心情點呀？有冇失去興趣做嘢？」(How's your mood?) | ~5% | |
| Hyperthyroidism | Weight loss despite good appetite, tremor, heat intolerance, tachycardia | 「有冇心跳快、手震、怕熱、食得多但瘦咗？」(Fast heart, tremor, heat intolerance?) | ~2% | |
| Diabetic autonomic neuropathy | Known DM, nocturnal diarrhoea, alternating with constipation [5] | 「你有冇糖尿病？半夜會唔會痾？」(Do you have DM? Diarrhoea at night?) | ~1% | |
| Trying to Tell Me Something? | Stress / anxiety / work pressure / fear of cancer | Hidden agenda beneath somatic complaint | 「你最擔心係咩呀？有冇嘢令你好大壓力？」(What worries you most? Any big stressors?) | ~10% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, set agenda | 「你好呀，我係今日嘅醫生。請問點稱呼你呀？今日咩事嚟睇醫生呀？」 | Friendly opening = interpersonal marks. Open question lets patient tell their story. |
| 0:30–1:30 | HPI – symptom analysis | 「肚痾咗幾耐呀？一日去幾多次？啲大便係水樣定有血有膿呀？有冇肚痛、嘔吐、發燒呀？」 | Duration, frequency, character, blood/mucus, associated Sx → builds chief complaint. |
| 1:30–2:30 | Red flags + focused Hx | 「體重有冇輕咗？有冇食過唔乾淨嘢、去過旅行、或者有冇人同你一齊肚痾呀？最近有冇食過抗生素或者其他藥？」 | Red flags (weight loss, blood), epidemiological clues, drug-induced diarrhoea → DDx. |
| 2:30–3:30 | PMH, DHx, FHx, Social Hx | 「你以前有冇腸胃病、糖尿病、或者甲狀腺問題呀？食緊咩藥？有冇藥物敏感？屋企人有冇類似嘅病？你做咩工作呀？食飯方面規唔規律？」 | Masquerades (DM neuropathy, hyperthyroidism, drugs). Social context for biopsychosocial. |
| 3:30–4:30 | ICE + Hidden agenda | 「你自己覺得係咩原因呀？（Ideas）你最擔心啲咩？（Concerns）你嚟到最希望醫生可以幫你做啲咩？（Expectations）」 | ICE = direct exam marks. Hidden agenda: maybe worried about cancer, IBD, or work impact. |
| 4:30–5:15 | Functional impact + psychosocial | 「肚痾對你返工/返學有冇影響呀？瞓得好唔好？有冇壓力或者心情唔好？」 | Biopsychosocial problems. Screen depression/anxiety (masquerade + IBS link). |
| 5:15–6:00 | Summarise, signpost, safety-net, close | 「等我總結吓：你肚痾咗X日⋯⋯我有冇漏咗啲咩？我想幫你檢查吓同做啲化驗。如果大便有血、發高燒、或者飲唔到水，就要即刻返嚟。」 | Summarising scores marks. Safety-net demonstrates safe practice. Checking understanding = empathy. |
Uncovering the hidden agenda: Ask 「其實你今日嚟最主要想解決咩問題呀？」 — the RFC is often NOT "diarrhoea" itself but fear of cancer, need for sick leave, travel concern, or worry about a chronic condition like IBD.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Duration | How long have you had diarrhoea? | 「肚痾咗幾耐呀？」 | Acute ( < 4 wk) vs chronic ( ≥ 4 wk) changes entire DDx [1] | Chronic → IBS, IBD, malabsorption, Ca colon |
| Frequency/Volume | How many times a day? Large or small amounts? | 「一日去幾多次？每次多唔多？」 | Large watery = secretory/osmotic; small frequent = inflammatory [1] | Large volume → infectious, secretory; small bloody → dysentery, IBD |
| Character | Watery, bloody, mucoid, or greasy/oily? | 「啲大便係水樣、有血、有膿、定係好油好臭？」 | Differentiates inflammatory vs watery vs fatty diarrhoea [1][2] | Blood/mucus → IBD, dysentery; fatty → malabsorption, chronic pancreatitis |
| Blood in stool | Any blood or dark stools? | 「有冇血或者黑色大便呀？」 | RED FLAG: Ca colon, IBD, dysentery | Refer urgently if > 50 y/o + rectal bleeding + weight loss |
| Abdominal pain | Any tummy pain? Where? | 「有冇肚痛？邊度痛呀？」 | LLQ cramp → inflammatory; periumbilical → IBS; RLQ → Crohn's/appendicitis | Cramping relieved by defecation → IBS |
| Fever | Any fever? | 「有冇發燒呀？」 | Fever → infectious/inflammatory cause | ≥ 38.5°C = indication for stool C/ST & empirical Abx [1] |
| Vomiting | Any vomiting? | 「有冇嘔呀？」 | Associated vomiting → viral GE, food poisoning, dehydration risk | V+D in < 6 h → preformed toxin (S. aureus, B. cereus) [3] |
| Weight loss | Any weight loss? | 「體重有冇輕咗？」 | RED FLAG: Ca colon, IBD, malabsorption, hyperthyroidism | Significant weight loss → urgent referral |
| Food history | Any raw/undercooked food, eating out, or spoiled food? | 「最近有冇食過生嘢、街邊嘢食、或者唔新鮮嘅嘢？」 | Incubation period helps identify pathogen [3]: < 6 h toxin, 8–16 h C. perfringens, > 16 h viral/bacterial | Raw oysters → Hep A, Vibrio; undercooked poultry → Campylobacter, Salmonella |
| Travel | Any recent travel? | 「最近有冇去過旅行呀？」 | Traveller's diarrhoea (ETEC, Giardia, amoeba) [4] | Tropical → parasites, typhoid |
| Contacts/cluster | Anyone else with the same symptoms? | 「屋企人或者同事有冇一齊肚痾？」 | Cluster → viral GE outbreak, food poisoning | Norovirus outbreaks common in HK |
| Drug history | Any medications? Antibiotics recently? | 「食緊咩藥呀？最近有冇食過抗生素？」 | Drug-induced diarrhoea is a key masquerade [1]: antibiotics → C. difficile; metformin, Mg-antacid, colchicine, PPI | Recent Abx → C. difficile (CDAD) |
| PMH | Diabetes? Thyroid problems? Previous bowel disease or surgery? | 「有冇糖尿病、甲狀腺問題、或者以前有冇腸道病？」 | DM autonomic neuropathy → nocturnal diarrhoea [5]; hyperthyroidism → chronic watery diarrhoea | Diabetic nocturnal diarrhoea; thyrotoxicosis |
| Allergy | Any drug allergies? | 「有冇藥物敏感呀？」 | Safety + exam requirement | — |
| Family history | Any bowel disease or cancer in the family? | 「屋企人有冇腸癌或者腸炎病史呀？」 | FHx IBD, colorectal Ca | FHx + rectal bleeding → urgent colonoscopy |
| Social/occupation | What's your job? Any stress? | 「做咩工作呀？最近壓力大唔大？」 | IBS strongly linked to stress; food handler → public health implications | Stress + abdominal pain relieved by defecation → IBS |
| Functional impact | How does this affect your daily life/work? | 「影響咗你返工/日常生活嗎？」 | Biopsychosocial assessment | — |
| Mood | Any low mood or anxiety? | 「心情點呀？有冇唔開心或者好緊張？」 | Depression as masquerade; anxiety worsens IBS | Depression can cause altered bowel habit |
| Lactose | Does milk or dairy make it worse? | 「飲牛奶或者食奶製品之後會唔會特別痾？」 | Lactase deficiency: up to 90% of adult Asians [3] | Osmotic diarrhoea after dairy → lactose intolerance |
Case Report Form Answer Builder
- Template: "Diarrhoea for [duration]"
- Must capture: Onset, duration (acute vs chronic), frequency, stool character (watery/bloody/fatty), volume, associated symptoms (pain location, fever, vomiting, weight loss), food/travel/contact Hx, drug Hx, dehydration status, red flags assessed and negative/positive.
- Likely examples: "Worried about persistent diarrhoea affecting work"; "Concerned about cancer"; "Wants medication to stop diarrhoea"; "Needs sick leave certificate"
- Best phrasing: Write ONE sentence combining symptom + motivation, e.g. "Patient presents with 5-day diarrhoea causing inability to work, seeking treatment and reassurance that it is not something serious."
| Example Wording | |
|---|---|
| Ideas | "I think I ate something bad" / "I'm worried it could be cancer" / "Maybe it's stress-related" |
| Concerns | "I'm worried because I saw blood" / "I'm scared of losing weight" / "Worried it won't stop" |
| Expectations | "I want medicine to stop the diarrhoea" / "I want a blood test/colonoscopy" / "I need a sick note" |
- Acute presentation (most common exam scenario): Acute gastroenteritis (viral or bacterial) — supported by acute onset, watery diarrhoea ± vomiting, contact/food Hx, self-limiting course, no red flags.
- Chronic presentation: IBS — supported by Rome IV criteria (recurrent abdominal pain ≥ 1 day/week in last 3 months, related to defecation, change in frequency/form, no red flags, no nocturnal symptoms).
- Minimum evidence to write: Duration + stool character + epidemiological context + absence of red flags.
| DDx | One Key Discriminator |
|---|---|
| IBD (UC or Crohn's) | Chronic bloody/mucoid diarrhoea + extraintestinal features (oral ulcers, arthritis, eye inflammation) |
| Drug-induced diarrhoea | Temporal relationship to medication initiation (metformin, antibiotics, PPI, Mg-antacid) |
| Colorectal carcinoma | Age > 50, rectal bleeding, iron-deficiency anaemia, weight loss, change in bowel habit |
Alternative DDx if scenario fits: Hyperthyroidism, C. difficile colitis, lactose intolerance, coeliac disease
| Domain | Example |
|---|---|
| Biological | Dehydration and electrolyte imbalance from ongoing fluid loss |
| Psychological | Anxiety about serious underlying cause (e.g., cancer worry) |
| Social/Functional | Inability to attend work/school; impact on daily activities and social life |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Acute gastroenteritis | Dry mucous membranes / reduced skin turgor (signs of dehydration) | Inspect oral mucosa, pinch skin on dorsum of hand | Confirms significant fluid loss from acute diarrhoea; determines need for rehydration |
| IBS | No reliable physical sign in brief FM station | Mild diffuse/LLQ tenderness on palpation (non-specific) | Diagnosis is clinical (Rome IV); exam is mainly to exclude red-flag signs. State: "Examination expected to be unremarkable, supporting functional diagnosis" |
| IBD (UC/Crohn's) | Perianal disease (fistula, skin tag, abscess) – especially Crohn's; or oral aphthous ulcers | Inspect perianal area; inspect oral cavity | Extraintestinal/perianal features are characteristic of Crohn's |
| Colorectal carcinoma | Palpable abdominal mass or blood on digital rectal examination | Abdominal palpation (RLQ/LLQ); DRE | Mass or blood on DRE with altered bowel habit strongly suggests malignancy |
| Hyperthyroidism | Goitre with lid retraction, tremor, tachycardia | Inspect and palpate neck; check pulse; observe for hand tremor | Thyrotoxic signs explain chronic watery diarrhoea as a systemic cause |
| C. difficile colitis | Fever + diffuse abdominal tenderness (may have distension) | Vital signs; abdominal palpation | Recent antibiotics + fever + tenderness = high suspicion for CDAD |
Top Traps That Lose Marks
- Forgetting to ask about medications — drug-induced diarrhoea (metformin, antibiotics, PPI, Mg-antacids) is a top masquerade and commonly tested [1].
- Not differentiating acute vs chronic — changes the entire differential; always clarify duration first.
- Missing red flags then writing IBS as diagnosis — IBS is a diagnosis of EXCLUSION. You must document that you screened for blood, weight loss, nocturnal symptoms, fever, anaemia, family Hx of Ca/IBD.
- Writing too many diagnoses instead of ONE main RFC — Q2 asks for ONE reason. Pick the most specific.
- Forgetting ICE — marks are given for specific patient-centred phrases, not generic statements.
- Not asking about lactose intolerance in an Asian patient — 90% prevalence of lactase deficiency in adult Asians [3].
- Ignoring psychosocial domain — Q5b needs at least one psychological AND one social problem.
Must-Not-Miss Red Flags — Urgent Referral
- Rectal bleeding + weight loss + age > 50 → urgent colonoscopy to r/o colorectal Ca
- Severe dehydration (altered consciousness, hypotension, oliguria) → A&E for IV rehydration
- High fever ( ≥ 38.5°C) + bloody diarrhoea → stool C/ST, empirical antibiotics, consider admission [1]
- Recent antibiotics + profuse diarrhoea → suspect C. difficile, request toxin assay
- Chronic diarrhoea with nocturnal symptoms, anaemia, raised inflammatory markers → suspect IBD/malignancy, refer for colonoscopy
Safety-net closing line: 「如果你發高燒、大便有血、飲唔到水、或者頭暈企唔穩，就要即刻去急症室。」 (If you develop high fever, blood in stool, can't keep fluids down, or feel dizzy/faint, go to A&E immediately.)
High Yield Summary
What to ASK: Duration (acute vs chronic), stool character (watery/bloody/fatty), food-travel-contact Hx, medications (especially antibiotics, metformin), red flags (blood, weight loss, nocturnal Sx, fever), dairy intolerance, thyroid Sx, DM Hx, stress/mood, ICE, functional impact.
What to WRITE: Chief complaint with duration + frequency + character. ONE clear RFC. Specific ICE. Most likely Dx with minimum 2–3 supporting points. Three DDx each with a discriminator. Biopsychosocial triad. Physical sign = dehydration signs (acute GE) or "unremarkable exam supporting functional diagnosis" (IBS).
What NOT to MISS: Drug-induced diarrhoea, colorectal Ca red flags, C. difficile in post-antibiotic patients, hyperthyroidism as masquerade, lactose intolerance in Asians, and always screen for the hidden agenda.
Active Recall - Family Medicine Clinical Test
[1] Senior notes: Ryan Ho GI.pdf (Section 3.1.3–3.1.4, Acute and Chronic Diarrhoea) [2] Lecture slides: Block A - Chronic diarrhoea_ irritable bowel syndrome and inflammatory bowel disease.pdf [3] Senior notes: Ryan Ho GI.pdf (Section on Lactose intolerance, p.130) [4] Lecture slides: GC 103. Fever after travelling.pdf [5] Senior notes: Block A - Deterioration of eyesight in a diabetic patient_ diabetic complications.pdf (Diabetic autonomic neuropathy — nocturnal diarrhoea) [6] Senior notes: Block A - Gastrointestinal Data Interpretation.pdf (Fecal calprotectin for IBD vs IBS)
Sore Throat
Sore throat is a painful inflammation of the pharynx, most commonly caused by viral or bacterial infections, resulting in odynophagia and pharyngeal erythema.
Dysuria
Dysuria is painful, burning, or uncomfortable sensation during urination, commonly caused by urinary tract infections, urethritis, or other genitourinary conditions.