Most Common HK Primary Care Symptoms
Shortness Of Breath / Dyspnoea
Dyspnoea is the subjective sensation of difficult, labored, or uncomfortable breathing arising from interactions among physiological, psychological, and environmental factors.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Asthma | Episodic wheeze + SOB, triggers (allergens, exercise, cold), reversibility on spirometry (≥12% improvement post-bronchodilator) [6] | 「你係唔係成日時好時壞？有冇嘢會令你發作？」 | ~20% |
| COPD | Chronic smoker, progressive exertional dyspnoea, productive cough; obstructive spirometry (FEV1/FVC < 0.7) [1][4] | 「你食咗幾多年煙？有冇長期咳同痰？」 | ~15% | |
| Heart failure (HFrEF/HFpEF) | PND, orthopnoea, bilateral ankle oedema, raised JVP, displaced apex beat, bilateral basal crackles [2][3] | 「瞓低會唔會更加辛苦？腳有冇腫？」 | ~10% | |
| Serious Not To Miss | Acute MI / ACS | Crushing chest pain, diaphoresis; ECG ST changes | 「有冇壓住嗰種胸口痛？有冇標冷汗？」 | ~3% |
| Pulmonary embolism | Acute pleuritic chest pain + dyspnoea, haemoptysis, VTE risk factors; sinus tachycardia, S1Q3T3 on ECG [7][8] | 「最近有冇長時間坐飛機或者唔郁？隻腳有冇腫？」 | ~2% | |
| Lung cancer | Persistent cough, haemoptysis, weight loss in a smoker; CXR mass | 「有冇咳血？有冇瘦咗？」 | ~1% | |
| Pneumothorax | Sudden onset pleuritic pain + SOB in tall thin young male or COPD patient; reduced breath sounds, hyper-resonant percussion [7] | 「係唔係突然間開始？」PE: 一邊冇呼吸聲 | < 1% | |
| Pitfalls | Anaemia | Gradual onset exertional SOB, pallor, fatigue; low Hb | 「有冇覺得好攰、面色差？」Look for conjunctival pallor | ~8% |
| Pleural effusion | Dullness to percussion, reduced breath sounds | 「有冇覺得一邊胸口好悶？」PE: stony dull percussion [9] | ~3% | |
| Interstitial lung disease (ILD / pneumoconiosis) | Progressive dyspnoea, dry cough, bibasilar velcro-like crackles, clubbing; occupational dust exposure [1] | 「做嘢有冇接觸石棉或者粉塵？」Examine nails for clubbing | ~2% | |
| Masquerades | Depression / Panic disorder | SOB with hyperventilation, perioral tingling, anxiety, no organic signs | 「你最近壓力大唔大？有冇突然間心跳好快、手腳痺？」 | ~10% |
| Thyrotoxicosis | SOB + palpitations, weight loss, heat intolerance, tremor | 「有冇心跳好快、手震、怕熱？」 | ~2% | |
| Metabolic acidosis (e.g. DKA) | Kussmaul breathing, known DM, polyuria/polydipsia [10] | 「你有冇糖尿病？最近有冇飲多咗水、去多咗廁所？」 | < 1% | |
| Trying to Tell Me Something? | Occupational stress / fear of cancer / financial worry | Patient uses SOB as ticket of entry; real concern is job loss, cancer fear, or family burden | 「除咗氣喘，仲有冇其他嘢令你擔心？你最擔心嘅係咩？」 | ~10% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, set agenda | 「你好，我係X醫生，今日會同你傾下你嘅情況，大概六分鐘左右。可唔可以同我講下你今日嚟睇咩事？」 (Hello, I'm Dr X, I'll chat with you for about 6 minutes. Can you tell me what brought you here today?) | Friendly opening + signposting → interpersonal marks. Sets time frame. |
| 0:30–2:30 | HPI: symptom analysis + red flags | 「你幾時開始覺得氣喘？」「行幾多路就開始喘？行樓梯呢？」「瞓低嗰陣會唔會覺得更加辛苦？要用幾多個枕頭？」「半夜有冇試過突然坐起身透氣？」「有冇胸口痛？有冇咳？痰係咩顏色？有冇咳血？」「腳有冇腫？」 | Covers onset/duration/severity/exacerbating-relieving factors, PND, orthopnoea, associated Sx. These discriminate cardiac vs respiratory. |
| 2:30–3:30 | PMHx, DHx, allergy, FHx, SHx | 「你以前有冇心臟病、高血壓、糖尿病、肺病？」「食緊啲咩藥？有冇藥物敏感？」「屋企人有冇心臟病或者肺病？」「你做咩工作？有冇食煙飲酒？食咗幾耐煙？每日幾多支？」 | Smoking (COPD), occupation (silicosis/asbestosis per GC083 [1]), drug history (ACEI cough, β-blocker), FHx (IHD). |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得呢個氣喘係咩原因？」(Ideas) 「你最擔心嘅係咩？」(Concerns) 「你今日嚟最想我幫你啲咩？」(Expectations) 「除咗氣喘之外，仲有冇其他嘢令你擔心？」 | ICE is directly tested on the Case Report Form. The last question uncovers hidden agenda (e.g., fear of lung cancer, work stress, can't work). |
| 4:30–5:15 | Functional impact + psychosocial | 「氣喘有冇影響到你返工或者日常生活？」「你心情點呀？有冇瞓得差？」「屋企有冇人可以照顧你？」 | Biopsychosocial problems for Q5b. |
| 5:15–5:45 | Summarise + check understanding | 「等我總結返：你話嗰陣開始覺得行路氣喘，越嚟越差…我有冇漏咗啲咩？」 | Summarising scores interpersonal marks and ensures accuracy. |
| 5:45–6:00 | Close + safety net | 「我會安排你做啲檢查。如果你突然好辛苦抖唔到氣、胸口好痛、或者嘴唇變紫，記住即刻去急症室。你仲有冇問題想問？」 | Safety netting + empathetic closure. |
Uncovering the hidden agenda: The RFC is NOT always the symptom. Ask "點解今日嚟？" — a patient may have had dyspnoea for weeks but comes today because a relative died of lung cancer, or they can no longer work. That answer IS the RFC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did SOB start? Sudden or gradual? | 「幾時開始覺得氣喘？係突然間定係慢慢嚟？」 | Acute → PE/PTX/APO; Chronic → COPD/HF/ILD [2][3] | Acute: PE, pneumothorax. Chronic: COPD, HF |
| Severity/Functional | How far can you walk? How many flights of stairs? | 「你而家行到幾遠？行幾多層樓梯就要停？」 | Quantifies severity; maps to NYHA / mMRC [4] | NYHA III–IV / mMRC ≥ 2 = significant |
| Exertional vs rest | SOB at rest or only on exertion? | 「靜靜坐住會唔會喘？定係行路先會？」 | Rest dyspnoea = more severe disease | Severe HF, severe COPD, PE |
| Orthopnoea | Do you need extra pillows to sleep? How many? | 「瞓低會唔會覺得辛苦啲？要幾多個枕頭？」 | Characteristic of cardiac dyspnoea [2][3] | HF (pulmonary congestion when supine) |
| PND | Do you wake up at night gasping for air? | 「半夜有冇試過突然醒咗，好辛苦咁抖唔到氣？」 | Characteristic of HF, not respiratory causes [2][3] | Heart failure |
| Cough/Sputum | Any cough? Phlegm colour? | 「有冇咳？有冇痰？咩顏色？」 | Purulent → infection; pink frothy → APO; dry → ILD/ACEI | Pneumonia, COPD exacerbation, HF, ILD |
| Haemoptysis | Any blood in phlegm? | 「有冇咳血？」 | Red flag: PE, lung Ca, TB | PE, malignancy, TB |
| Chest pain | Any chest pain? What kind? | 「有冇胸口痛？係壓住咁定係拮住咁？」 | Central crushing → ACS; pleuritic → PE/PTX | ACS, PE, pneumothorax |
| Wheeze | Any wheezing sound? | 「呼吸嗰陣有冇「咇咇」聲？」 | Airway obstruction | Asthma, COPD |
| Leg swelling | Any leg swelling? One side or both? | 「腳有冇腫？一隻腳定兩隻腳？」 | Bilateral → HF; unilateral → DVT/PE | HF, DVT→PE |
| Smoking Hx | Do you smoke? How many years/day? | 「你有冇食煙？食咗幾多年？每日幾多支？」 | Pack-years → COPD, lung Ca risk [1][4] | COPD, lung cancer |
| Occupation | What is your job? Dust/chemical exposure? | 「你做咩嘢工作？有冇接觸塵或者化學品？」 | Occupational lung disease (silicosis, asbestosis) per GC083 [1] | ILD/pneumoconiosis |
| PMHx | Any heart disease, DM, HTN, lung disease? | 「以前有冇心臟病、糖尿、高血壓、哮喘或者肺病？」 | Known cardiac/respiratory disease changes pre-test probability | HF exacerbation, COPD exacerbation |
| Drug Hx | Current medications? ACEI? β-blockers? | 「而家食緊咩藥？」 | ACEI → cough; β-blocker → bronchospasm; methotrexate → lung toxicity [5] | Drug-induced cough/bronchospasm |
| Allergy | Any drug allergy? Atopic history? | 「有冇藥物敏感？有冇濕疹、鼻敏感？」 | Atopy → asthma | Asthma |
| FHx | Family history of heart/lung disease? | 「屋企人有冇心臟病或者肺病？」 | Familial IHD, asthma | IHD, asthma |
| Weight loss | Any weight loss? | 「有冇瘦咗？」 | Red flag for malignancy, TB | Lung Ca, TB |
| Fever | Any fever? | 「有冇發燒？」 | Infection: pneumonia, TB, IE | Pneumonia, IE |
| Mood | How is your mood? Sleep OK? | 「你心情點呀？有冇瞓得差？」 | Depression masquerade; anxiety → hyperventilation | Panic disorder, depression |
| Travel/Immobilisation | Recent travel/surgery/bed rest? | 「最近有冇去旅行、做手術或者長時間唔郁？」 | VTE risk factors | PE |
Case Report Form Answer Builder
Write: "Shortness of breath for [duration]" then cover:
- Onset (acute vs gradual), duration, progression
- Severity (how far can walk / stairs / rest dyspnoea)
- Exacerbating factors (exertion, lying flat, cold air, allergens)
- Relieving factors (rest, sitting up, bronchodilator)
- Associated symptoms: cough ± sputum (colour), chest pain (type), wheeze, haemoptysis, leg swelling, fever, weight loss
- PND, orthopnoea (number of pillows)
- Relevant PMHx (IHD, HTN, DM, asthma, COPD), DHx, smoking (pack-years), occupation
Examples — pick the ONE that fits the scenario:
- "Progressive SOB affecting ability to work"
- "Worsening SOB with fear of lung cancer"
- "New-onset SOB wanting diagnosis and treatment"
- The RFC is why they came today, not just the symptom. Always ask "點解今日嚟？".
| Likely Examples | Exact Wording for CRF | |
|---|---|---|
| Ideas | "I think it might be my heart" / "Maybe from smoking" | "Patient thinks SOB may be due to his heart / his smoking habit" |
| Concerns | "I'm worried it could be cancer" / "Afraid I'll die in my sleep" | "Patient is worried about lung cancer / worried about dying at night" |
| Expectations | "I want a chest X-ray" / "I want medicine to help me breathe" | "Patient expects investigation (CXR) and treatment for symptom relief" |
Choose based on the clinical stem. Common FM clinical-test scenarios:
| Scenario Clue | Most Likely Dx | Minimum Evidence |
|---|---|---|
| Long-time smoker, progressive exertional SOB, productive cough | COPD | Smoking ≥20 pack-years + chronic cough/sputum + exertional dyspnoea |
| Known HTN/IHD, PND, orthopnoea, ankle oedema | Heart failure | PND + orthopnoea + ankle oedema + ↑JVP / displaced apex / bilateral basal crackles |
| Young patient, episodic wheeze, atopy | Asthma | Variable SOB + wheeze + triggers + personal/family atopy |
| Construction worker, dry cough, exertional dyspnoea | Pneumoconiosis / ILD [1] | Occupational exposure + dry cough + bibasilar velcro crackles + clubbing |
| DDx | One-Line Discriminator |
|---|---|
| Heart failure | PND, orthopnoea, bilateral ankle oedema, ↑JVP, bilateral basal crackles |
| COPD | Smoking history, chronic productive cough, barrel chest, prolonged expiration, wheeze |
| Asthma | Episodic, variable, reversible airway obstruction, triggers, atopy |
| PE | Acute onset, pleuritic pain, haemoptysis, unilateral leg swelling, VTE risk factors |
| ILD / Pneumoconiosis | Occupational exposure, dry cough, velcro crackles, restrictive spirometry, clubbing |
| Anaemia | Pallor, fatigue, SOB on exertion without respiratory/cardiac signs |
| Lung cancer | Smoking, haemoptysis, weight loss, hoarseness, CXR mass |
(Pick three that contrast with your most likely Dx.)
| Domain | Example |
|---|---|
| Biological | Chronic airflow limitation (COPD) / Reduced cardiac output (HF) / Anaemia |
| Psychological | Anxiety about diagnosis (fear of cancer) / Depression from functional limitation / Poor sleep from PND |
| Social / Functional | Unable to work (especially manual labour) / Social isolation due to exercise intolerance / Financial burden of treatment / Caregiver burden on family |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Dx |
|---|---|---|---|
| Heart failure | Raised JVP | Patient at 45°, look at internal jugular vein; measure height above sternal angle | Indicates elevated right atrial pressure from fluid overload / pump failure [2][3] |
| Heart failure (alt) | Displaced apex beat | Palpate apex in left lateral decubitus; displaced = lateral to MCL / below 5th ICS | Indicates cardiomegaly / LV dilatation |
| COPD | Barrel chest with prolonged expiratory phase + diffuse wheeze | Inspect AP diameter; time I:E ratio on auscultation | Hyperinflation + airflow obstruction [4] |
| Asthma | Polyphonic expiratory wheeze | Auscultate chest; ask patient to breathe deeply | Indicates widespread small airway obstruction; may be absent between attacks |
| ILD / Pneumoconiosis | Bilateral fine inspiratory "velcro-like" basal crackles + clubbing [1] | Auscultate lung bases; inspect nails for clubbing | Fibrotic lung → characteristic velcro crackles; clubbing supports chronicity |
| PE | Unilateral calf swelling + tenderness (DVT signs) | Measure bilateral calf circumference; palpate | Concurrent DVT supports VTE as cause of acute SOB |
| Pneumothorax | Absent breath sounds + hyper-resonant percussion on one side | Percuss and auscultate both hemithoraces | Air in pleural space → absent BS + hyper-resonance |
| Anaemia | Conjunctival pallor | Pull down lower eyelid, inspect conjunctival colour | No reliable respiratory/cardiac signs in pure anaemia; pallor is best clue in brief FM station |
| Lung cancer | No single reliable brief-station sign; clubbing, lymphadenopathy, or signs of SVC obstruction may be present | Inspect hands, palpate supraclavicular fossa | Often no sign in early disease; CXR is the key investigation |
Top Traps That Lose Marks
- Forgetting to ask ICE — this is directly tested on the Case Report Form. Students who skip it lose easy marks.
- Not asking PND & orthopnoea — these are the key discriminators between cardiac and respiratory dyspnoea. If you don't ask, you can't distinguish HF from COPD.
- Ignoring occupational history — GC083 specifically tests pneumoconiosis in a construction worker [1]. Occupation is a must-ask.
- Forgetting smoking history in pack-years — essential for COPD and lung cancer risk stratification.
- Writing "SOB" as the RFC — the RFC is why they came today, not the symptom name. Always phrase it as a sentence including the patient's perspective.
- Missing PE as a DDx in acute SOB — always ask about VTE risk factors (immobility, travel, OCP, recent surgery).
- Forgetting anaemia as a masquerade — SOB with no wheeze, no crackles, no cardiac signs → think anaemia.
- Not safety-netting — mention when to go to A&E (sudden worsening, chest pain, cyanosis).
Must-not-miss red flags → urgent referral:
- Acute severe SOB at rest with cyanosis, altered consciousness
- Sudden pleuritic chest pain + haemoptysis (PE)
- Crushing chest pain + diaphoresis (ACS)
- Stridor (upper airway obstruction)
- Massive haemoptysis
- New unilateral leg swelling (DVT → PE)
Shortest safe management / safety-net line:
「如果你突然好辛苦抖唔到氣、胸口好痛、嘴唇變紫、或者咳血，記住即刻打999或者去急症室。」
High Yield Summary
What to ASK: Onset/duration, severity (functional capacity), PND, orthopnoea (pillows), cough/sputum/haemoptysis, chest pain, wheeze, leg swelling, fever, weight loss, smoking pack-years, occupation (dust!), PMHx (cardiac/respiratory), DHx (ACEI, β-blocker), ICE, hidden agenda.
What to WRITE on Case Report Form:
- Q1 HPI: Duration, progression, severity, PND/orthopnoea, associated Sx, smoking, occupation, PMHx
- Q2 RFC: Why they came TODAY (e.g., "Progressive SOB now unable to work, seeking diagnosis")
- Q3 ICE: Specific patient words
- Q4 Most likely Dx with ≥3 supporting clinical features
- Q5a: Three DDx with discriminators
- Q5b: One bio + one psych + one social problem
- Q6: One physical sign matching most likely Dx (see table above)
What NOT to MISS:
- SOB is very sensitive but NOT specific — must differentiate cardiac vs respiratory vs other [2][3]
- PND = characteristic of cardiac (HF), not respiratory [2][3]
- BNP distinguishes cardiac from respiratory SOB [3]
- Occupational exposure → pneumoconiosis/ILD (GC083) [1]
- Velcro crackles + clubbing = ILD (GC083) [1]
- PE in any acute SOB — always screen VTE risk factors
Active Recall - Family Medicine Clinical Test
[1] GC 083. Shortness of breath in a construction site worker.pdf (signs and symptoms of ILD/pneumoconiosis, occupational exposure) [2] Ryan Ho Fundamentals.pdf (p.204, p.222-223: Dyspnoea D/dx, cardiac vs respiratory dyspnoea table, history approach) [3] GC 084. Shortness of breath on exertion.pdf (SOB is sensitive but not specific; BNP for cardiac vs respiratory) [4] Maksim Medicine Notes.pdf (p.280: Dyspnoea DDx; p.299-301: COPD assessment, mMRC scale, GOLD criteria) [5] Block A - Hematology Interactive Tutorial.pdf (p.2: Methotrexate lung, NSAID-related GI bleeding causing anaemia) [6] MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.187-189: Asthma definition, reversibility, exacerbation severity) [7] learning_points_output.txt (Two Cases of Acute SOB: PE Well's score, D-dimer, PTX management) [8] Ryan Ho Haemtology.pdf (p.131: PE clinical features, Wells score, diagnostic evaluation) [9] 2024 Fourth Summative MCQ.pdf (p.37: EMQ - stony dull percussion = pleural effusion, bilateral fine basal crackles + JVP not raised = ILD) [10] Block A - Electrolyte and Acid-Base Disorders.pdf (p.3: Kussmaul breathing in metabolic acidosis)
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.
Numbness / Tingling (paraesthesia)
Paraesthesia is an abnormal sensory perception of numbness, tingling, or "pins and needles" resulting from dysfunction or irritation of peripheral or central sensory neural pathways.