Most Common HK Primary Care Symptoms
Localised Lump
A localized lump is a discrete, palpable mass confined to a specific anatomical area, arising from abnormal growth or swelling of tissue such as a cyst, abscess, lipoma, or neoplasm.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Lipoma | Soft, lobulated, mobile, non-tender, subcutaneous, NOT attached to skin [1] | Palpation: soft, slippery, can pinch skin above freely | ~25% |
| Sebaceous (epidermoid) cyst | Punctum on surface, smooth, mobile, attached to skin [1] | 「上面有冇一個黑色細窿？」(any central punctum?) | ~20% | |
| Reactive lymph node | Recent infection, tender, mobile, < 1 cm, regresses | 「最近有冇病過、喉嚨痛或者傷風？」 | ~15% | |
| Serious Not To Miss | Malignant lymph node (lymphoma / metastasis) | Hard, non-tender, fixed, > 2 cm, progressive, ± B-symptoms [2] | 「有冇瘦咗、出夜汗、發燒？」 | ~3% |
| Skin cancer (SCC / BCC / melanoma) | Non-healing ulcer, irregular border, colour change, sun-exposed site [2] | 「粒嘢有冇爛咗好耐都唔好？有冇變色？」 | ~2% | |
| Breast cancer (if breast lump) | Hard, irregular, painless, skin tethering/peau d'orange, axillary LN [2] | 「皮膚有冇好似橙皮噉？有冇凹咗入去？」(dimpling / peau d'orange) | ~2% | |
| Soft tissue sarcoma | Deep, > 5 cm, firm, rapid growth, fixed to deep structures | Palpation: deep to fascia, immobile on muscle contraction | < 1% | |
| Pitfalls | Abscess (early, without fluctuance) | Warm, tender, erythematous, evolving | 「摸落去有冇覺得暖暖哋同痛？」 | ~10% |
| Ganglion cyst | Firm, over joint/tendon, transilluminates | Transillumination positive | ~8% | |
| Hernia (inguinal/femoral) | Reducible, cough impulse, in groin/scrotal region | 「你咳一吓」(cough impulse); 「瞓低之後有冇縮返入去？」 | ~5% | |
| Masquerades | Thyroid nodule (if anterior neck) | Moves with swallowing, thyroid status symptoms [3] | 「吞口水嗰陣粒嘢有冇郁？有冇心跳快、手震、出汗？」 | ~5% |
| Dermoid cyst / thyroglossal cyst (paediatric / midline neck) | Midline, moves with tongue protrusion (thyroglossal) | 「伸條脷出嚟」(ask to protrude tongue) | ~2% | |
| Trying to Tell Me Something? | Cancer anxiety / health anxiety | Disproportionate worry, FHx cancer, recent bereavement | 「你最擔心嘅係咩？有冇屋企人試過有類似情況？」 | ~25% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日由我同你傾吓。請問我可以點稱呼你呀？」「今日你嚟呢度有咩嘢想睇呀？」 | Scores interpersonal marks: greeting, uses patient's name, open question |
| 0:30–1:30 | HPI – characterise the lump (site, onset, duration, size change, pain, skin change, discharge) | 「嗰粒嘢喺邊度呀？」「幾時開始發現㗎？」「有冇越嚟越大？」「痛唔痛呀？」「上面皮膚有冇變色、損咗、或者流嘢出嚟？」 | Core symptom analysis; drives diagnosis |
| 1:30–2:30 | Red flags & targeted systems review (weight loss, night sweats, fever, other lumps, bleeding, appetite) | 「近排有冇瘦咗呀？」「有冇夜晚出好多汗？」「有冇發燒？」「身體其他地方有冇類似嘅嘢？」 | Must not miss malignancy / infection |
| 2:30–3:30 | PMHx, DHx, FHx, Allergy, Social Hx | 「你有冇長期病㗎？食緊咩藥？」「有冇藥物敏感？」「屋企人有冇試過生咁嘅嘢或者癌症㗎？」「你做咩工作㗎？食唔食煙飲唔飲酒？」 | Completeness of case report |
| 3:30–4:30 | ICE – uncover hidden agenda | 「你自己覺得呢粒嘢係咩嚟㗎？」(Idea)「你最擔心嘅係咩呢？」(Concern)「你今日嚟最想我幫你做到啲咩？」(Expectation) | ICE is a scored section; hidden agenda often = cancer worry |
| 4:30–5:15 | Signpost → focused physical exam discussion | 「我想了解多少少，如果需要嘅話，我可以檢查吓嗰粒嘢，你介唔介意？」 | Permission scores; links history to examination |
| 5:15–6:00 | Summarise, safety-net, close | 「等我總結吓：你喺（部位）發現咗粒嘢，已經有（時間），你最擔心係（concern）。我建議幫你安排檢查，如果粒嘢突然變大、痛、或者流血，請即刻嚟返。有冇其他嘢想問？」 | Summary + safety-net + checking understanding = high marks |
Hidden agenda tip: For a localised lump, the patient often comes because they fear cancer (癌症). Ask 「你最擔心嘅係咩？」 early to unlock this – it is frequently the ONE main reason for consultation. [1]
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Site | Where exactly is the lump? | 「粒嘢喺邊度呀？」 | Anatomical site narrows DDx hugely (neck vs breast vs groin vs skin) | Neck → thyroid/LN; Breast → fibroadenoma/CA; Groin → hernia/LN |
| Onset & Duration | When did you first notice it? | 「幾時開始發現㗎？」 | Acute = abscess/cyst; chronic/slow = benign; rapid growth = malignancy | Weeks-months progressive → malignancy red flag [2] |
| Size change | Has it grown bigger? | 「有冇越嚟越大呀？」 | Progressive enlargement = red flag | Rapid ↑ → malignancy, haemorrhage into cyst |
| Pain | Is it painful? | 「痛唔痛呀？」 | Pain → infection/inflammation; painless lump → malignancy | Painful: abscess, inflamed cyst; Painless: lipoma, malignancy [1] |
| Skin changes | Any redness, ulcer, or discharge? | 「上面有冇紅、爛咗、或者流膿？」 | Skin involvement → epidermal origin, malignancy, or infection [1] | Punctum → sebaceous cyst; ulcer → SCC/BCC; peau d'orange → CA breast |
| Number | Any other lumps elsewhere? | 「身體其他地方有冇其他粒嘢？」 | Multiple = lipomatosis, generalised lymphadenopathy, NF | Multiple → systemic disease |
| Red flags: B-symptoms | Weight loss, night sweats, fever? | 「有冇瘦咗、夜晚出汗、發燒？」 | Constitutional symptoms → lymphoma, metastatic CA, TB | Lymphoma, metastatic malignancy |
| Trauma / cause | Any injury or insect bite? | 「有冇撞親或者俾蟲咬？」 | Traumatic origin → haematoma, foreign body granuloma | Haematoma, reactive swelling |
| Function | Does it affect your daily life? | 「有冇影響你日常生活？」 | Functional impact = biopsychosocial domain | Cosmetic distress, restricted movement |
| PMHx | Any chronic illness or previous cancer? | 「有冇長期病或者以前有冇生過癌症？」 | Previous malignancy → metastasis; DM → abscess risk | Metastatic node, diabetic abscess |
| DHx | Any medication? Anticoagulants? | 「食緊咩藥？有冇食薄血丸？」 | Anticoagulants → haematoma | Warfarin-related haematoma |
| Allergy | Any drug allergy? | 「有冇藥物敏感？」 | Safety; Case Report requirement | — |
| FHx | Any family history of lumps or cancer? | 「屋企人有冇試過生粒嘢或者有癌症？」 | FHx breast CA, thyroid CA, NF, MEN | Hereditary cancer syndromes |
| Social | Smoking? Alcohol? Occupation? Sun exposure? | 「食唔食煙？飲唔飲酒？做咩工作？有冇成日曬太陽？」 | Sun → skin CA; occupation → exposure | Outdoor work + sun → SCC/BCC/melanoma [2] |
| Sexual / menstrual (if breast) | Last menstrual period? Cyclical change? | 「你最後一次嚟M幾時？粒嘢有冇跟住月經變大縮細？」 | Cyclical breast lump → fibroadenosis; pregnancy → physiological | Fibrocystic change, lactational abscess |
| ICE | What do you think it is? What worries you? What do you want me to do? | 「你自己覺得係咩？最擔心咩？想我點幫你？」 | Scored directly in Case Report | Cancer fear = common hidden agenda |
Case Report Form Answer Builder
- Format: "Localised lump at [site] for [duration]"
- Capture: site, onset, duration, size change, pain, skin changes, discharge, associated symptoms (red flags), functional impact
- Example: "A painless, gradually enlarging lump on the right side of the neck for 3 months, with no skin changes, no B-symptoms"
- Most likely: "Patient noticed the lump is getting bigger and is worried it might be cancer"
- Alternatives: cosmetic concern; pain/discomfort interfering with daily life; advised by family member to seek medical attention
- Phrase it from the patient's perspective, not the disease perspective
| Component | Likely Example | Exact Wording for CRF |
|---|---|---|
| Idea | Patient thinks it might be a tumour/cancer | "Patient thinks the lump may be cancerous" |
| Concern | Fear of malignancy; fear of surgery | "Patient is worried it could be cancer and is afraid of needing an operation" |
| Expectation | Wants reassurance, investigation, or removal | "Patient hopes to have the lump checked and removed if necessary" |
Choose based on presentation cues:
- Subcutaneous, soft, mobile, no skin attachment → Lipoma
- Central punctum, attached to skin, expressible → Sebaceous (epidermoid) cyst [1]
- Young woman, smooth round mobile breast lump → Fibroadenoma
- Neck lump moving with swallowing → Thyroid nodule [3]
- Tender, red, warm → Abscess
- Support with minimum evidence: site + consistency + mobility + skin attachment + duration
| DDx | Key Discriminator |
|---|---|
| Lipoma | Soft, lobulated, subcutaneous, freely mobile, no punctum |
| Sebaceous cyst | Punctum, attached to skin, may express cheesy material |
| Lymphadenopathy (reactive vs malignant) | Location in LN drainage area, tenderness (reactive) vs hard/fixed (malignant) |
(Adjust based on site: if breast → fibroadenoma, breast cyst, CA breast; if neck → thyroid nodule, LN, branchial cyst; if groin → hernia, LN, saphena varix)
| Domain | Problem |
|---|---|
| Biological | Risk of malignancy requiring investigation (e.g. triple assessment for breast, FNAC/biopsy for suspicious lump) |
| Psychological | Anxiety about cancer / fear of surgery |
| Social | Impact on work/daily activities; cosmetic concern affecting self-image; financial worry about medical costs |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Sebaceous (epidermoid) cyst | Central punctum visible on inspection [1] | Inspect overlying skin carefully; look for a small dark dot on the summit | Pathognomonic: punctum = blocked sebaceous duct opening; no other lump has this sign |
| Lipoma | Soft, lobulated, freely mobile mass with normal overlying skin; can pinch skin above it [1] | Pinch skin over lump → skin moves freely (not attached); palpate → soft, slippery edges | Confirms subcutaneous, non-epidermal origin; distinguishes from cyst (attached to skin) |
| Breast cancer | Skin dimpling or peau d'orange [2] | Ask patient to raise arms → look for skin tethering / dimpling; inspect for orange-peel skin | Indicates tethering of Cooper's ligaments by tumour; highly specific for malignancy |
| Malignant lymph node | Hard, non-tender, fixed node > 2 cm | Palpate – assess consistency, mobility, tenderness | Hard + fixed + non-tender = red flag for malignancy vs soft/tender = reactive |
| Abscess | Fluctuance + warmth + erythema | Press centre with one finger, feel periphery with another; compare temperature to surrounding skin | Fluctuance = pus collection; warmth/erythema = active infection |
| Thyroid nodule | Lump moves with swallowing [3] | Ask patient to swallow a sip of water; observe lump movement | Thyroid is attached to pretracheal fascia → moves with swallowing; other neck lumps do not |
| Inguinal hernia | Cough impulse | Place fingers over lump and ask patient to cough | Expansile cough impulse = communication with peritoneal cavity |
| Ganglion cyst | Transillumination positive | Darken room, place penlight against lump; observe light transmission | Cystic fluid-filled → transilluminates; solid lumps do not |
Top Traps That Lose Marks
- Forgetting to ask about red flags (B-symptoms, rapid growth, fixity) → loses marks in HPI and misses serious DDx
- Not asking ICE → entire scored section lost; cancer worry is almost always the hidden concern
- Describing the lump without stating relationship to skin and deep structures → cannot distinguish epidermoid cyst (attached to skin) from lipoma (subcutaneous, NOT attached to skin) from deep lesions [1]
- Not asking about site-specific questions: breast lump without asking about nipple discharge/menstrual cyclicity; neck lump without asking about swallowing movement/thyroid symptoms
- Writing "to rule out malignancy" as the RFC → RFC should be patient-centred (e.g. "worried it might be cancer"), not doctor-centred
- Forgetting to examine regional lymph nodes when examining any lump → always mentioned in clinical demonstration [1]
Must-not-miss red flags → urgent referral:
- Hard, fixed, rapidly growing, painless lump
- Non-healing ulcer > 3 weeks
- B-symptoms (weight loss, night sweats, fever)
- Skin changes suggesting malignancy: irregular border, colour change, ulceration, peau d'orange [2]
- Supraclavicular lymphadenopathy (Virchow's node) → intra-abdominal malignancy
- New lump in patient with known cancer history
Shortest safe management / safety-net line:
「如果粒嘢突然變大、痛、出血、或者有其他新嘅嘢出現，請即刻返嚟睇。我會安排進一步檢查，唔使太擔心。」 (If the lump suddenly gets bigger, becomes painful, bleeds, or new symptoms appear, come back immediately. I'll arrange further investigation. Don't worry too much.)
High Yield Summary
What to ASK: Site, onset, duration, size change, pain, skin changes (punctum, ulcer, colour), attachment, mobility, B-symptoms, ICE – especially cancer fear as hidden agenda.
What to WRITE on CRF:
- Chief complaint: "Localised [site] lump for [duration]"
- RFC: Patient-centred – usually "worried about cancer"
- ICE: Idea = cancer; Concern = fear of malignancy/surgery; Expectation = investigation/reassurance/removal
- Most likely Dx: Based on site + consistency + skin attachment + mobility
- DDx: 3 alternatives with discriminators
- Biopsychosocial: biological (investigation need), psychological (cancer anxiety), social (work/cosmetic impact)
- Physical sign: Punctum (sebaceous cyst), soft/mobile/skin-free (lipoma), skin tethering (CA breast), moves with swallowing (thyroid), fluctuance (abscess)
What NOT to MISS: Hard/fixed/painless/rapidly growing → malignancy until proven otherwise. Always examine regional lymph nodes [1]. Triple assessment for any breast lump [2].
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: Clinical Demonstration_Skin.pdf (Introduction, History, Physical Examination sections) [2] Lecture slides: GC 201. Skin ulcers skin and subcutaneous lesions; skin cancer.pdf; GC 181. Breast mass breast cancer; benign breast diseases; mammography; breast cancer screening.pdf [3] Senior notes: Ryan Ho Endocrine.pdf (p18 – D/dx of anterior neck lump, thyroid nodule examination)
Oral / Dental Pain
Oral or dental pain is nociceptive or inflammatory pain arising from structures of the teeth, gingiva, oral mucosa, or jaw, most commonly caused by dental caries, pulpitis, periodontal disease, or abscess.
Nausea / Vomiting
Nausea is the unpleasant sensation of an urge to vomit, while vomiting is the forceful expulsion of gastric contents through the mouth, both mediated by the brainstem vomiting center in response to various peripheral or central stimuli.