Most Common HK Primary Care Symptoms
Epigastric Pain
Epigastric pain is discomfort localized to the upper central abdomen, commonly associated with gastritis, peptic ulcer disease, pancreatitis, or gastroesophageal reflux.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Functional Dyspepsia [8] | Young, chronic, no alarm features, normal OGD | 「你幾大？呢個情況持續咗幾耐？」(Age < 40, no red flags) | ~30% |
| GERD | Burning retrosternal/epigastric, worse lying flat, heartburn | 「有冇胃酸湧上嚟嘅感覺？瞓低有冇差啲？」 | ~25% | |
| Peptic Ulcer Disease (GU/DU) [1] | Burning/gnawing epigastric pain; meal-related; Hx NSAIDs / H. pylori | 「食完嘢之後個痛好啲定差啲？有冇食止痛藥？」 | ~15% | |
| Serious Not To Miss | Acute coronary syndrome / MI [9] | Epigastric pain + sweating, SOB, risk factors (DM, HTN, smoking) | 「有冇標冷汗？有冇氣促？」 | ~3% |
| Acute pancreatitis [2][3] | Severe pain radiating to back, relieved leaning forward, Hx alcohol/gallstones | 「痛去唔去背脊？向前傾有冇好啲？飲唔飲酒？」 | ~2% | |
| Gastric carcinoma [7] | Age > 45 + alarm features (weight loss, dysphagia, anaemia, FHx) | 「有冇瘦咗？食嘢吞唔吞到？」 | ~1% | |
| Pancreatic carcinoma [10] | Painless jaundice, weight loss, new-onset DM, gnawing back pain | 「有冇眼黃？大便有冇變淺色？」 | <1% | |
| Perforated PUD | Sudden severe pain → rigid abdomen, board-like guarding | PE: 板狀腹 (board-like rigidity), rebound tenderness | <1% | |
| Pitfalls | Biliary colic / cholecystitis [5] | Intense constant RUQ/epigastric pain after fatty meal; not true colic | 「食完肥膩嘢有冇右邊肋骨下面痛？」Murphy's sign | ~10% |
| Mesenteric ischaemia [2] | Pain out of proportion to signs, Hx AF/vascular disease | 「有冇心律不齊？」Check for AF | <1% | |
| Masquerades | Drug-induced dyspepsia | NSAIDs, aspirin, steroids, iron, bisphosphonates [8] | 「有冇食以下嘅藥？」(List drugs) | ~15% |
| Depression | Chronic dyspepsia with somatisation | 「心情點？瞓得好唔好？」 | ~10% | |
| DKA [2] | Known DM + abdominal pain, polyuria, polydipsia, Kussmaul breathing | 「你有冇糖尿病？」Check Hstix | <1% | |
| Trying to Tell Me Something? | Work stress / fear of cancer / family issues | Patient worried about cancer after relative's diagnosis; stress-related FD | 「你最擔心係咩？」「屋企或者工作有冇特別壓力？」 | ~10% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, set agenda | 「你好，我係今日嘅醫生，請問點稱呼你？」「今日想了解下你嘅情況，我會問你幾個問題，之後睇下可以點樣幫到你，好唔好？」 | Friendly opening + signposting = interpersonal marks |
| 0:30–2:30 | HPI – SOCRATES + associated Sx | 「可唔可以話俾我聽，你邊度唔舒服？」「呢個痛幾時開始？」「個痛係咩感覺？好似火燒定係脹痛？」「有冇去到其他地方，例如背脊？」「食完嘢之後好啲定差啲？」「有冇嘔、作嘔、嘔血、痾黑色屎？」「有冇食少咗嘢或者瘦咗？」 | Covers chief complaint, red flags, and discriminators for PUD vs biliary vs pancreatitis vs malignancy [1][2] |
| 2:30–3:30 | Red flags + systems review | 「有冇覺得吞嘢困難？」「有冇皮膚或者眼白變黃？」「大便習慣有冇改變？」「有冇心口痛或者氣促？」 | Screens for GI malignancy, cardiac cause, cholangitis |
| 3:30–4:30 | PMH, Drug, Family, Social Hx | 「以前有冇乜嘢病？有冇食止痛藥例如布洛芬？」「有冇飲酒、食煙？飲幾多？」「屋企人有冇胃癌或者胃病？」「做咩工作㗎？」 | NSAIDs, aspirin, H. pylori and alcohol are top risk factors per GC slides [1][2]. Occupation/stress → biopsychosocial |
| 4:30–5:15 | ICE – uncover hidden agenda | 「你自己覺得呢個痛可能係咩原因？」(Ideas) 「你最擔心啲乜嘢？」(Concerns) 「你今日嚟想我點樣幫到你？」(Expectations) 「點解揀今日嚟睇醫生呢？」(Hidden agenda – RFC) | ICE = direct Case Report Form marks. "Why today?" often reveals the real RFC (e.g. worried about cancer, pain affecting work) |
| 5:15–5:45 | Summarise back to patient | 「等我重複一次你講嘅嘢，睇下有冇遺漏：你話上腹痛咗XX日，食完嘢會…，你擔心…，啱唔啱？」 | Checking understanding = high interpersonal mark |
| 5:45–6:00 | Close + safety net | 「我會安排幫你做檢查，如果痛得好厲害、嘔血或者痾黑色屎，要即刻去急症室，好嗎？」 | Safe closure; safety-net statement essential |
Hidden agenda tip: If the patient is middle-aged with new-onset epigastric pain, the hidden concern is often fear of stomach cancer, especially if a relative had it. Always ask 「你有冇擔心係唔好嘅嘢？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site | Where exactly is the pain? Point with one finger | 「可唔可以用手指指下邊度痛？」 | Localises to epigastrium vs RUQ vs diffuse [2] | Epigastric → PUD, pancreatitis; RUQ → biliary |
| Onset/Duration | When did it start? Sudden or gradual? | 「幾時開始痛？突然定係慢慢嚟？」 | Sudden severe → perforation, pancreatitis, ACS [1] | Acute pancreatitis, perforated PUD |
| Character | What does the pain feel like – burning, cramping, tearing? | 「個痛係咩感覺？好似火燒、實實哋、定係痙攣咁？」 | Burning/gnawing = PUD; intense dull constant = biliary; severe radiating to back = pancreatitis [1][2] | See discriminators |
| Radiation | Does the pain go to your back? | 「有冇痛去背脊？」 | Radiation to back → pancreatitis, posteriorly penetrating PUD, dissecting aneurysm [2][3] | Pancreatitis, AAA |
| Meal relationship | Does eating make it better or worse? | 「食完嘢之後好啲定差啲？」 | GU pain ↑ with food; DU pain ↓ with food (relieved by eating/antacid) [1][4] | GU vs DU |
| Aggravating | Worse lying flat? Leaning forward? Fatty food? | 「瞓低有冇差啲？向前傾有冇好啲？食肥膩嘢有冇差啲？」 | Relieved by leaning forward → pancreatitis [3]; worse after fatty meal → biliary [5] | Pancreatitis, biliary colic |
| Nausea/Vomiting | Any nausea or vomiting? | 「有冇作嘔或者嘔？」 | Associated with pancreatitis, biliary, GOO [2] | Pancreatitis, GOO |
| GI bleeding | Any vomiting blood or black tarry stools? | 「有冇嘔血？大便有冇黑色好似柏油咁？」 | Red flag for bleeding PUD or malignancy [6] | Bleeding PUD, gastric CA |
| Weight loss | Any unintentional weight loss? | 「體重有冇無啦啦輕咗？」 | Alarm feature for malignancy [7][8] | Gastric CA, pancreatic CA |
| Dysphagia | Any difficulty swallowing? | 「吞嘢有冇困難？」 | Alarm feature [7] | Oesophageal/gastric CA |
| Jaundice | Have your eyes or skin turned yellow? | 「眼白或者皮膚有冇變黃？」 | Obstructive jaundice → CBD stone, pancreatic head CA [5] | Choledocholithiasis, pancreatic CA |
| NSAIDs/Drugs | Are you taking any painkillers like ibuprofen or aspirin? | 「有冇食止痛藥例如布洛芬？有冇食薄血丸？」 | NSAIDs/aspirin = major risk factor for PUD [1][2][6] | Drug-induced PUD |
| H. pylori | Have you ever been tested or treated for stomach bacteria? | 「有冇驗過幽門螺旋菌？有冇食過殺菌藥？」 | H. pylori = commonest cause of PUD [1][2] | H. pylori–related PUD |
| Alcohol | How much alcohol do you drink? | 「你飲唔飲酒？大約飲幾多？」 | Alcohol → pancreatitis, gastritis, Mallory-Weiss [2][3] | Acute pancreatitis |
| Smoking | Do you smoke? | 「你有冇食煙？」 | Risk factor for PUD, gastric CA [1] | PUD, gastric CA |
| Family Hx | Any family history of stomach cancer or GI disease? | 「屋企人有冇胃癌或者胃病？」 | FHx GI cancer = alarm feature [7] | Gastric CA |
| Cardiac Sx | Any chest tightness, shortness of breath, or jaw pain with exertion? | 「行路嗰陣有冇心口翳、氣促、或者下巴痛？」 | MI can present as epigastric pain – must not miss [1][9] | Inferior MI / ACS |
| Stress/Mood | Have you been under a lot of stress? Any low mood? | 「最近壓力大唔大？心情點？」 | Functional dyspepsia; psychosocial axis [8] | FD, anxiety, depression |
| Functional impact | Does the pain affect your work or daily life? | 「呢個痛有冇影響到你返工或者日常生活？」 | Biopsychosocial / social problem for Case Report | Social problem |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Safety; mandatory to ask | — |
Case Report Form Answer Builder
- CC: Epigastric pain × [duration]
- HPI high-yield points to capture:
- SOCRATES: site, onset, character, radiation, associations, timing, exacerbating/relieving, severity
- Meal relationship (better/worse with food)
- Associated GI symptoms: nausea, vomiting, haematemesis, melaena, heartburn, dysphagia, weight loss, change in bowel habit
- Risk factors: NSAIDs/aspirin, H. pylori status, alcohol, smoking
- Red flags/alarm features: age > 45, weight loss, GI bleeding, dysphagia, family history GI CA
- Relevant PMH (DM, IHD, previous PUD/OGD), drug history, allergy
- Not always "epigastric pain" — look for why today?
- Likely examples:
- "Worried the pain may be stomach cancer after a relative was diagnosed"
- "Pain is now affecting work/sleep"
- "Wants referral for endoscopy"
- "Pain not relieved by over-the-counter antacids"
- Phrasing: Write the patient's own reason, e.g. "Patient is concerned that persistent epigastric pain may indicate a serious stomach disease and would like investigation."
| Component | Likely Example | Exact Wording for CRF |
|---|---|---|
| Ideas | "I think I might have a stomach ulcer" / "Maybe it's from the painkillers" | Patient thinks the pain may be due to stomach ulcer / medication side effect |
| Concerns | "I'm worried it could be stomach cancer" | Patient is worried the pain could be due to gastric cancer, especially as [relative had it / symptoms worsening] |
| Expectations | "I want to have a scope done" / "I want medicine to stop the pain" | Patient expects referral for endoscopy / wants medication for symptom relief |
- In a typical FM station with a middle-aged patient on NSAIDs or with meal-related burning pain: Peptic Ulcer Disease [1][2]
- If young patient < 40, no alarm features, chronic vague discomfort: Functional Dyspepsia [8]
- Minimum supporting evidence for PUD:
- Burning/gnawing epigastric pain
- Meal relationship (GU worse / DU better with food)
- Risk factors: NSAID use and/or H. pylori
- ± epigastric tenderness on exam
| DDx | One Key Discriminator |
|---|---|
| GERD | Burning retrosternal/epigastric pain, worse lying flat, heartburn, acid regurgitation [8] |
| Biliary colic / Cholecystitis | Intense constant RUQ/epigastric pain after fatty meal, radiates to scapula, Murphy's sign +ve [5] |
| Gastric carcinoma | Age > 45, alarm features (weight loss, anaemia, dysphagia), epigastric mass [7] |
Alternative high-yield DDx if the stem suggests:
| Domain | Problem |
|---|---|
| Biological | Epigastric pain with risk of complications (bleeding, perforation); need investigation to exclude malignancy |
| Psychological | Anxiety about possible stomach cancer / health anxiety; or low mood if chronic |
| Social | Pain affecting work productivity / sleep disturbance / dietary limitations / financial burden of investigations |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| PUD (most likely) | Epigastric tenderness | Palpate epigastrium with flat hand, observe for tenderness | Localised tenderness at the site of ulcer; PE: epigastric tenderness is the most reliable sign in PUD [1][4]. Note: PE is often unremarkable in uncomplicated PUD — epigastric tenderness is the best available sign. |
| Biliary colic / Cholecystitis | Murphy's sign (inspiratory arrest on RUQ palpation) | Hook fingers under right costal margin, ask patient to breathe in deeply | Positive Murphy's = inflamed gallbladder contacts examining hand → specific for cholecystitis [5] |
| Acute pancreatitis | Epigastric tenderness with guarding ± Grey Turner's / Cullen's sign | Inspect flanks and periumbilical area; palpate epigastrium | Ecchymosis = retroperitoneal haemorrhage in severe necrotising pancreatitis [3] |
| Gastric carcinoma | Palpable epigastric mass ± Virchow's node (left supraclavicular LN) | Palpate epigastrium; palpate left supraclavicular fossa | Palpable mass = advanced disease; Virchow's node = intra-abdominal malignancy [7] |
| GERD | No reliable specific physical sign in a brief FM station | — | Diagnosis is clinical (typical symptoms); best exam clue: no epigastric mass, no tenderness, symptom pattern |
| ACS / MI | Diaphoresis, hypotension, new murmur | Vitals; auscultate heart | Sweating + epigastric pain + abnormal vitals → suspect cardiac; order ECG [9] |
| Perforated PUD | Board-like rigidity, rebound tenderness | Palpate abdomen gently | Peritonism = surgical emergency |
Top Traps That Lose Marks
- Forgetting to exclude ACS/MI – epigastric pain CAN be inferior MI. Always ask about cardiac risk factors and sweating. Per GC slides, MI can radiate to the epigastrium [9].
- Not asking about NSAIDs/aspirin – this is the most commonly tested drug history for epigastric pain. Drug history is critical [1][2][6].
- Calling biliary colic a "true colic" – per GC lecture, biliary pain is intense, constant and dull, NOT truly colicky [2][5].
- Forgetting alarm features – age > 45, weight loss, dysphagia, GI bleeding, anaemia, FHx GI cancer → mandatory OGD referral [7][8].
- Not asking ICE – easy marks lost. Always ask all three explicitly.
- Writing "epigastric pain" as the RFC – the RFC is WHY they came TODAY, not the symptom. Dig for the hidden agenda.
- Confusing GU vs DU pain pattern – GU: pain worse with food; DU: pain relieved by food, worse at night [1][4].
Must-not-miss red flags for urgent referral:
- Haematemesis / melaena → urgent OGD
- Sudden severe pain + rigid abdomen → suspect perforation → A&E
- Chest pain + sweating + SOB → suspect ACS → ECG + troponin
- Progressive dysphagia + weight loss → urgent OGD for malignancy
- Jaundice + epigastric mass → suspect pancreatic CA → urgent imaging + surgical referral
Safety-net closing line: 「如果痛得好厲害、嘔血、痾黑色屎、或者心口好翳，要即刻去急症室。」(If the pain becomes very severe, you vomit blood, pass black tarry stools, or have severe chest tightness, go to A&E immediately.)
High Yield Summary
What to ASK: SOCRATES for pain, meal relationship (GU vs DU), radiation to back (pancreatitis), NSAIDs/aspirin, H. pylori, alcohol, alarm features (weight loss/dysphagia/GI bleeding/age > 45/FHx CA), cardiac symptoms, ICE, and "why today?"
What to WRITE: CC with duration → HPI in SOCRATES → risk factors → red flags → ICE → RFC (the real reason, not just the symptom) → Most likely Dx = PUD (if typical) or FD (if young, no alarms) → DDx = GERD, biliary, gastric CA → Biopsychosocial → Physical sign = epigastric tenderness
What NOT to MISS: ACS masquerading as epigastric pain; perforated PUD; gastric malignancy in patient > 45 with alarm features; NSAIDs as the culprit; biliary pain is constant not colicky
Active Recall - Family Medicine Clinical Test
[1] GC 092. Upper abdominal pain: peptic ulcer; pancreatitis and gallstone.pdf [2] Block A - Upper abdominal pain_ peptic ulcer; pancreatitis and gallstone.pdf (Pain severity & DDx sections) [3] MBBS Final MB (Surgery) (Felix PY Lai).pdf (Pancreatitis: pp. 580–581, 593) [4] MBBS Final MB (Surgery) (Felix PY Lai).pdf (PUD: p. 389–391) [5] MBBS Final MB (Surgery) (Felix PY Lai).pdf (Gallstones & biliary colic: p. 510) [6] Block A - Coffee ground vomitus tarry stool upper GI bleeding.pdf (Risk factors for UGIB) [7] GC 212. Weight loss and vomiting gastric cancer; abdominal imaging.pdf [8] Ryan Ho GI.pdf (Approach to Dyspepsia & Functional Dyspepsia: pp. 53–54); Ryan Ho Fundamentals.pdf (pp. 263–264) [9] CFB (MED05) Cardiovascular (I) Physical Examination (History Taking).pdf (Chest pain DDx table) [10] WCS 056 - Painless jaundice and epigastric mass - by Prof R Poon.ppt (1).pdf
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