Most Common HK Primary Care Symptoms
Headache
Headache is a painful sensation in any region of the head, ranging from sharp to dull, that may arise from primary neurological mechanisms or secondary to an underlying medical condition.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Tension-type headache | Bilateral, band-like, no N/V, wax-and-wane, stress-related | 「頭痛係唔係兩邊、好似條帶咁箍住？」 | ~50% |
| Migraine | Unilateral pulsatile, 4–72h, N/V, photo/phonophobia, debilitating (POUND) [3][6] | 「痛嗰陣會唔會跳住痛、想嘔、怕光？」 | ~20% | |
| Serious Not To Miss | Brain tumour / ↑ICP | Progressive headache, worse morning/Valsalva, focal deficit, papilloedema [5] | 「頭痛係唔係一路惡化？朝早特別痛？」 | ~1% |
| Subarachnoid haemorrhage | Thunderclap "worst headache of my life" ± LOC, meningism [1][2] | 「有冇試過突然之間好似爆炸咁痛，一世人咁痛？」 | <1% | |
| Meningitis/encephalitis | Fever + headache + neck stiffness + confusion | 「有冇發燒、頸硬、意識模糊？」 | <1% | |
| GCA (temporal arteritis) | Age > 50, temporal tenderness, jaw claudication, ↑ESR [8] | 「食嘢嗰陣會唔會覺得顎骨好攰好痛？」 | <1% | |
| Pitfalls | Medication overuse headache | Analgesic ≥ 15 d/month; headache paradoxically worsens | 「你止痛藥一個月食幾多日？」 | ~10% |
| Cervical spondylosis (referred) | Occipital, a/w neck stiffness/pain, worse with neck movement | 「痛係唔係喺後尾枕，郁條頸痛啲？」 | ~5% | |
| Acute glaucoma | Eye pain + red eye + halos + decreased vision + hard globe [10] | 「眼有冇痛、紅、睇嘢有光圈？」 | <1% | |
| Masquerades | Depression | Low mood, anhedonia, insomnia, somatic headache | 「最近有冇心情低落、對嘢冇興趣？」 | ~10% |
| Drug-induced headache | Nitrates, CCB, cilostazol, OCP [4] | 「最近有冇食新藥？」 | ~5% | |
| Phaeochromocytoma | Classic triad: headache + sweating + tachycardia; paroxysmal HTN [11] | 「痛嗰陣有冇標汗、心跳得好快？」 | <1% | |
| Trying to Tell Me Something? | Psychosocial stress / anxiety | Work/family stress, exam pressure, health anxiety (fear of brain tumour) | 「最近有冇乜嘢事令你壓力好大？」 | ~20% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好呀，我係X醫生。今日想傾下你嘅情況，大概會問下你嘅頭痛同埋其他相關問題，最後睇下可以點樣幫到你，好唔好？」 | Scores interpersonal marks: greeting, introduction, signposting, permission |
| 0:30–2:30 | HPI — SOCRATES of headache + red flags | 「頭痛幾時開始㗎？」「痛喺邊度？一邊定兩邊？」「點痛法？跳住痛定好似條帶咁箍住？」「有幾痛呀，十分入面你畀幾多分？」「有冇嘢令到佢痛啲或者好啲？」「痛嗰陣有冇覺得想嘔、怕光怕嘈？」「有冇試過好突然好嚴重嘅頭痛，好似爆炸咁？」(thunderclap) 「有冇發燒、頸硬、手腳冇力？」 | Captures chief complaint + red flags systematically; directly maps to Case Report Q1 |
| 2:30–3:30 | PMH, drug Hx, allergy, family Hx, social Hx | 「之前有冇乜嘢病底？」「而家食緊乜嘢藥？有冇食止痛藥？食咗幾耐？」「有冇藥物敏感？」「屋企人有冇偏頭痛或者其他嚴重病？」「你做咩工作？最近瞓得好唔好？有冇飲酒食煙？」 | Medication overuse headache is a common pitfall; social Hx screens psychosocial |
| 3:30–4:30 | ICE — uncover hidden agenda | 「你自己覺得頭痛係乜嘢原因呢？」(Ideas)「有冇特別擔心嘅嘢？例如驚係腦入面有嘢？」(Concerns)「你今日嚟最想我幫你做啲乜？」(Expectations)「點解揀今日嚟睇呢？」(hidden agenda — RFC) | ICE = core exam marks (Q3); "Why today?" reveals the real RFC |
| 4:30–5:15 | Focused systems review + functional impact | 「有冇影響到你返工或者湊小朋友？」「有冇心情唔好，訓唔著？」「有冇視嘢模糊、成日撞到嘢？」 | Biopsychosocial problems (Q5b); screens depression masquerade |
| 5:15–6:00 | Summarise, empathy, safety-net, close | 「等我總結下：你頭痛咗__，主要係__，最擔心__。我理解你嘅擔心。」「如果突然頭痛好嚴重、嘔、手腳冇力、或者講嘢唔清楚，要即刻去急症室。」「有冇嘢想補充？」 | Summarising + empathy + safety-net + checking understanding all score interpersonal marks |
Uncovering the hidden agenda: The presenting symptom is headache, but the RFC is often a specific fear (e.g. brain tumour, stroke) or a functional trigger (e.g. headache affecting work/exams, relationship stress). Always ask 「點解揀今日嚟睇呢？最近有冇咩事令你特別擔心？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset | When did it start? Sudden or gradual? | 「幾時開始痛？係突然之間痛定慢慢嚟？」 | Thunderclap onset → SAH [1][2] | SAH, dissection, CVST |
| Site | One side or both? Where exactly? | 「痛邊度？一邊定兩邊？眼周圍痛？」 | Unilateral → migraine/cluster; bilateral → TTH/↑ICP | Periorbital → cluster/glaucoma |
| Character | Throbbing, band-like, or stabbing? | 「點痛法？跳住痛、箍住痛、定刺痛？」 | Pulsatile + unilateral + N/V = migraine (POUND mnemonic) [3] | Migraine, TTH, neuralgia |
| Severity | How severe, 0–10? | 「十分入面幾痛？有冇影響到你做嘢？」 | Debilitating → migraine; "worst ever" → SAH | SAH if worst-ever headache |
| Duration | How long does each episode last? | 「每次痛幾耐？」 | 4–72h = migraine; 15min–3h = cluster; 30min–7d = TTH [3][4] | Classifies primary headache |
| Frequency | How often? How many days/month? | 「一個月痛幾多日？」 | > 15 days/month → chronic; medication overuse? | Chronic migraine, MOH |
| Aggravating | Worse with cough/bending/lying? | 「咳嗽、彎低身或者瞓低嗰陣會唔會痛啲？」 | Worse supine/Valsalva → ↑ICP [2][5] | SOL, hydrocephalus, IIH |
| Relieving | Better in dark room? With rest? | 「瞓喺暗房會唔會好啲？」 | Dark quiet room → migraine; restless → cluster | Primary headache type |
| Aura | Flashing lights or zigzag lines before? | 「痛之前有冇閃光、鋸齒形嘅嘢喺眼前？」 | Visual aura (scintillating scotoma) = classical migraine [6] | Migraine with aura |
| N/V, photo/phonophobia | Nausea, vomiting, light/noise sensitive? | 「有冇覺得想嘔？怕光怕嘈？」 | Key migraine features [3] | Migraine |
| Autonomic features | Eye tearing, nose blocked, eye red? | 「痛嗰邊有冇流眼水、鼻塞、眼紅？」 | Ipsilateral autonomic = cluster / TAC [4] | Cluster headache |
| Fever/neck stiffness | Any fever or stiff neck? | 「有冇發燒？條頸硬唔硬？」 | Meningism → meningitis/SAH [1][2] | CNS infection, SAH |
| Neuro symptoms | Weakness, numbness, speech problem? | 「手腳有冇冇力、痺、講嘢唔清楚？」 | Focal deficit → stroke/SOL [5] | Stroke, brain tumour |
| Vision | Blurred vision, visual field loss? | 「有冇視嘢模糊或者盲咗一邊？」 | Bitemporal hemianopia → pituitary tumour [7]; amaurosis fugax → GCA | Pituitary tumour, GCA, glaucoma |
| Jaw claudication/scalp tenderness (if > 50y) | Pain when chewing? Scalp tender? | 「食嘢咀嚼嗰陣會唔會痛？摸頭皮有冇痛？」 | Jaw claudication = GCA [8] | GCA — urgent |
| PMH | Any prior diagnoses? | 「之前有冇乜嘢病底？高血壓、糖尿病？」 | HTN → hypertensive crisis; cancer → mets | Secondary causes |
| Drug Hx | What medications? Painkillers how often? | 「而家食緊乜嘢藥？止痛藥一星期食幾多日？」 | Analgesic > 15 days/month → medication overuse headache (MOH) [4] | MOH — common pitfall |
| Allergy | Drug allergies? | 「有冇藥物敏感？」 | Safety | — |
| Family Hx | Family history of migraine? | 「屋企人有冇偏頭痛？」 | 70% migraineurs have +ve FHx [3] | Migraine |
| Social Hx | Work, stress, sleep, alcohol, smoking | 「做咩工作？最近壓力大唔大？瞓得好唔好？有冇飲酒？」 | Stress/sleep → TTH; alcohol trigger → cluster [4] | TTH, cluster, depression |
| Mood | Feeling down? Anxious? | 「最近心情點？有冇唔開心、好大壓力？」 | Depression masquerade [9] | Depression, anxiety |
| Functional impact | Affecting work/daily life? | 「有冇影響到你返工、做家務？」 | Q5b social problem | Disability |
| Menstrual (if female) | Relation to period? OCP use? | 「頭痛同月經有冇關係？有冇食避孕藥？」 | Menstrual migraine; OCP + migraine with aura → stroke risk [3] | Migraine, contraindication to OCP |
Case Report Form Answer Builder
- CC: Headache for [duration]
- HPI high-yield points to capture:
- SOCRATES: site (uni/bilateral), onset (sudden vs gradual), character (pulsatile/band-like/stabbing), radiation, associated symptoms (N/V, photophobia, phonophobia, aura, autonomic features), timing (duration of each attack, frequency, diurnal pattern), exacerbating/relieving factors, severity
- Red flags screened: SNOOP (systemic symptoms, neurological signs, onset sudden, other features, progression) [12]
- Temporal profile: acute/subacute/chronic; episodic vs daily
- Medication use: type, frequency, response
- Examples:
- "Patient presented because headache has become more frequent and is worried it could be a brain tumour"
- "Patient came today because headache is affecting work performance"
- "Patient's family member recently had a stroke, prompting concern"
- How to phrase: One sentence linking the symptom to the patient's reason for attending today. Always ask 「點解揀今日嚟？」
| Component | Likely Examples | Exact Wording for CRF |
|---|---|---|
| Ideas | "I think it might be stress" / "I worry it's a brain tumour" | "Patient thinks the headache is caused by work stress" |
| Concerns | Fear of brain tumour, stroke, aneurysm; fear of medication side effects | "Patient is worried that the headache could be due to a brain tumour" |
| Expectations | Wants a brain scan / wants reassurance / wants stronger painkillers / wants a referral | "Patient expects to have a CT brain scan to rule out serious causes" |
- In most FM station setups: Tension-type headache (most common) or Migraine (if unilateral, pulsatile, N/V, photophobia)
- Minimum supporting evidence for TTH: bilateral, band-like, no N/V, stress-related, no red flags
- Minimum supporting evidence for migraine: ≥2 of POUND criteria [3]
| DDx | Key Discriminator |
|---|---|
| Migraine (if TTH is main dx) or TTH (if migraine is main dx) | Character + associated symptoms |
| Medication overuse headache | Analgesic ≥ 15 d/month, paradoxical worsening |
| Cervical spondylosis (referred headache) | Occipital location, neck stiffness, worse with movement |
(If red flags present, swap in SAH, brain tumour, meningitis, or GCA as appropriate)
| Domain | Example |
|---|---|
| Biological | Recurrent headache with inadequate pain control / medication overuse |
| Psychological | Anxiety about brain tumour / underlying depression / stress |
| Social | Reduced work productivity / inability to care for children / social withdrawal |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Tension-type headache | Pericranial muscle tenderness on palpation | Palpate temporalis, frontalis, masseter, trapezius with firm rotary pressure | Tenderness of pericranial muscles is the hallmark physical finding in TTH |
| Migraine | No reliable physical sign during interval; during attack — photophobia elicited by penlight | Ask patient to look at bright light | Migraine is a clinical diagnosis; exam is typically normal between attacks. If during attack: allodynia, photophobia |
| SAH | Neck stiffness (meningism) [1][2] | Passive neck flexion — resistance/pain; Kernig's/Brudzinski's sign | Blood in subarachnoid space irritates meninges |
| Meningitis | Neck stiffness + fever | Passive neck flexion; check temperature | Meningeal inflammation |
| Brain tumour / ↑ICP | Papilloedema on fundoscopy [5] | Direct ophthalmoscopy — blurred disc margins, loss of venous pulsation | Raised ICP causes optic disc swelling |
| GCA | Tender, thickened, non-pulsatile temporal artery [8] | Palpate superficial temporal artery — tenderness, beading, reduced/absent pulse | Inflamed temporal artery in GCA |
| Acute glaucoma | Hard globe on palpation + mid-dilated fixed pupil [10] | Gentle bidigital tonometry; examine pupil | Raised intraocular pressure |
| Cluster headache | Ipsilateral conjunctival injection, lacrimation, ptosis (partial Horner's) during attack [4] | Observe during attack — eye red, tearing, droopy lid | Trigeminal autonomic activation |
Must-Not-Miss Red Flags — SNOOP
SNOOP mnemonic for headache red flags [12]:
- Systemic symptoms (fever, weight loss, cancer, immunocompromised, pregnancy)
- Neurological symptoms (confusion, focal deficits, seizures, papilloedema, meningism)
- Onset sudden/new — thunderclap = SAH until proven otherwise → urgent NCCT brain → LP if CT negative [1][2]
- Other features (trauma, worse supine/Valsalva, visual symptoms, medication overuse)
- Progression or change in pattern of previous headache
Urgent referral if any SNOOP red flag is present.
Top traps that lose marks:
- Forgetting to ask about medication overuse — analgesic ≥ 15 d/month is one of the most common missed diagnoses in FM
- Not asking ICE — students lose Q3 marks entirely by not exploring ideas, concerns, and expectations
- Not asking "Why today?" — the RFC is often different from the headache itself (e.g. a colleague had a stroke)
- Jumping to red flags without characterising the headache first — SOCRATES comes before red flags
- Forgetting GCA in patients > 50 — always ask about jaw claudication and scalp tenderness [8]
- Writing "migraine" as diagnosis without supporting criteria — need ≥2 of POUND
- Not mentioning a psychological problem in Q5b — depression/anxiety is almost always relevant in chronic headache
- Missing menstrual migraine trigger in females — high-yield for FM
Safety-net closing line: 「如果你突然之間頭痛好嚴重、嘔、手腳冇力、講嘢唔清楚、或者發燒頸硬，要即刻去急症室。」
High Yield Summary
What to ASK: SOCRATES → red flags (SNOOP) → medication use → ICE → "Why today?" → mood → functional impact
What to WRITE:
- Q1: CC with duration + key SOCRATES points + red flags screened
- Q2: One sentence linking symptom to why the patient came today
- Q3: Patient's own idea, specific concern, and what they want done
- Q4: TTH or migraine (most likely in FM) with minimum criteria
- Q5a: Migraine/TTH (whichever isn't Q4) + MOH + cervical spondylosis (or SAH/GCA if red flags)
- Q5b: Bio (headache itself) + Psych (anxiety/depression) + Social (work/family impact)
- Q6: Pericranial tenderness (TTH) or papilloedema (↑ICP) or temporal artery tenderness (GCA)
What NOT to MISS: Thunderclap → SAH; age > 50 new headache → GCA; analgesic overuse → MOH; mood → depression masquerade
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 109. Headache and loss of consciousness Acute stroke, subarachnoid haemorrhage and vascular malformation.pdf (pp. 16, 1–2) [2] Lecture slides: GC 082. Severe headache_headache and neuralgia; neuro-imaging I.pdf (p. 45) [3] Senior notes: Adrian Lui Pediatrics Notes.pdf (pp. 109, 111) [4] Senior notes: Maksim Medicine Notes.pdf (p. 255) [5] Senior notes: Ryan Ho Neurology.pdf (p. 57) [6] Past papers: 2021 Fourth Summative Assessment MCQ.pdf (Q40, p. 15) [7] Senior notes: Block A - I keep on bumping into people on my side_ pituitary tumours; hypopituitarism.pdf (p. 1) [8] Senior notes: Block A - Rheumatology Interactive Tutorial.pdf (p. 1) — GCA/PMR case [9] Senior notes: Ryan Ho Fundamentals.pdf (pp. 312–313) [10] AOS material: AOS - Ophthalmology.pdf (p. 6) — acute glaucoma scenario [11] Senior notes: Block A - I have fluctuating BP_ cushing syndrome; adrenal diseases and tumours; other endocrine tumours.pdf (p. 24) [12] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p. 1143) — SNOOP mnemonic
Foot And Ankle Pain
Foot and ankle pain is a common musculoskeletal complaint arising from traumatic, degenerative, inflammatory, or biomechanical disorders affecting the bones, joints, tendons, ligaments, or soft tissues of the foot and ankle complex.
Chest Pain
Chest pain is a symptom of discomfort or pain in the thoracic region that may originate from cardiac, pulmonary, gastrointestinal, musculoskeletal, or psychogenic causes, requiring prompt evaluation to exclude life-threatening conditions.