Family medicine
LLQ Pain
Left lower quadrant pain is abdominal pain localized below the umbilicus and to the left of midline, most commonly associated with diverticulitis, ovarian pathology, or colonic disorders.
Murtagh Diagnostic Strategy
GC 195 slide: LLQ differential includes sigmoid diverticulitis, cancer of sigmoid colon, torsion of ovarian cyst, ruptured ectopic pregnancy, ureteric colic, inguinal/femoral hernia, testicular pathology [1]. This is high yield for the in-house written exam.
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Sigmoid diverticulitis [1][2] | LLQ pain + low-grade fever + altered bowel habit in patient > 50; LLQ tenderness ± palpable mass [2] | 「你有冇發低燒？大便有冇變？」 |
| IBS | Recurrent crampy abdominal pain relieved by defecation, no red flags, younger patient | 「肚痛之後去完廁所有冇好啲？」 | |
| Serious Not To Miss | Colorectal (sigmoid) carcinoma [1] | Change in bowel habit, weight loss, PR bleeding in patient > 50, FH | 「大便習慣有冇改變？有冇瘦咗？」 |
| Ruptured ectopic pregnancy [1] | Reproductive-age ♀, missed period, sudden LLQ pain, haemodynamic instability | 「月經有冇遲咗？有冇突然好痛同埋頭暈？」 | |
| Ovarian torsion [1] | Sudden severe LLQ pain, nausea/vomiting, known ovarian cyst | 「係咪突然好痛？之前有冇卵巢水瘤？」 | |
| Strangulated inguinal/femoral hernia [1] | Tender irreducible groin lump + signs of IO | Examine groin for tender lump; 「你腳罅有冇脹起嘅嘢？」 | |
| Pitfalls | Ureteric colic [1] | Colicky flank-to-groin pain, haematuria, restlessness | 「個痛有冇去到腰同腳罅？小便有冇血？」 |
| UTI / pyelonephritis | Dysuria, frequency, fever, loin tenderness | 「小便有冇痛？有冇去得好密？」 | |
| PID [1] | Bilateral lower abdominal pain, vaginal discharge, fever, cervical motion tenderness | 「有冇分泌物？有冇發燒？下面痛唔痛？」 | |
| IBD (Crohn's/UC) | Chronic/relapsing bloody diarrhea, weight loss, extra-intestinal manifestations, young patient | 「有冇反覆肚痾帶血？關節有冇痛？」 | |
| Masquerades | Depression/stress (→ IBS) | Mood, sleep, appetite changes; pain with no organic finding | 「你心情點呀？瞓得好唔好？」 |
| Spinal (referred pain from lumbar spine) | Positional pain, dermatomal distribution, back pain | 「腰骨有冇痛？郁動有冇影響？」 | |
| DKA (abdominal pain) | Known diabetic, polyuria, Kussmaul breathing | 「你有冇糖尿病？口渴唔渴？」 | |
| Trying to Tell Me Something? | Cancer anxiety (relative recently diagnosed) | Ask about trigger for attendance | 「你最擔心啲咩？屋企有冇人最近唔舒服？」 |
| Domestic violence (abdominal trauma) | Inconsistent story, bruising, reluctance to answer | 「呢個痛之前有冇撞到或者受過傷？」 |
LLQ Pain — Family Medicine Clinical Test Page
| 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，今日想同你傾下你嘅情況，可以嗎？」(Hi, I'm Dr X, can we chat about your situation today?) | Interpersonal marks: warmth, greeting, permission |
| 0:30–1:30 | Open question → Chief complaint & HPI (SOCRATES) | 「你今日嚟主要係咩事呀？」→「個痛係幾時開始㗎？」「痛嘅感覺係點樣㗎？脹痛定刺痛？」「有冇去到其他地方？」 | Captures chief complaint, onset, character, radiation, severity |
| 1:30–2:30 | Red flags & associated symptoms | 「有冇嘔、肚痾、出血、大便有冇血？」「體重有冇輕咗？」「有冇發燒？」「小便有冇痛或者有血？」 | Identifies serious disorders not to miss |
| 2:30–3:30 | Menstrual/sexual/obstetric Hx (if female) + targeted systems review | 「你月經正唔正常呀？最後一次月經幾時？」「有冇性生活？有冇用避孕？」「有冇分泌物或者落面痛？」 | Critical: ectopic pregnancy, PID, ovarian cyst — commonly tested |
| 3:30–4:15 | PMH, Drug Hx, Allergy, FH, Social Hx | 「以前有冇咩病？食緊咩藥？有冇敏感？屋企人有冇腸癌或者炎症腸病？你食唔食煙飲唔飲酒？」 | Completeness marks |
| 4:15–5:00 | ICE + Hidden agenda | 「你自己覺得可能係咩事呀？」(Ideas) 「你最擔心啲咩？」(Concerns) 「你今日嚟最希望我幫到你啲咩？」(Expectations) 「點解揀咗今日嚟呢？」(Hidden agenda) | ICE is a dedicated mark section. Hidden agenda often = cancer fear, or fear of surgery, or relationship concern |
| 5:00–5:45 | Brief summary + signpost management | 「等我總結返：你左下腹痛咗X日，伴隨…我覺得最大可能係…我建議做返啲檢查…」 | Summarising scores marks; shows clinical reasoning |
| 5:45–6:00 | Safety net + close | 「如果個痛突然好勁、發高燒、嘔血或者暈低，要即刻去急症室㗎。」「你有冇其他嘢想問？」 | Safety net and closure both score interpersonal marks |
Uncovering the hidden agenda: Ask 「點解揀咗今日嚟睇醫生呢？」 — the patient may have had LLQ pain for weeks but came today because a relative was diagnosed with colon cancer, or they noticed blood in stool, or they have a relationship/fertility concern.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Pain onset | When did the pain start? Sudden or gradual? | 「個痛幾時開始㗎？係突然定慢慢嚟？」 | Sudden → torsion/ectopic rupture; gradual → diverticulitis, IBD | Ovarian torsion, ruptured ectopic |
| Character | Dull ache vs sharp vs crampy? | 「個痛係脹痛、刺痛定一陣陣絞住痛？」 | Colicky → ureteric colic/bowel; constant → diverticulitis/abscess | Ureteric colic, diverticulitis |
| Radiation | Does pain go anywhere else? | 「個痛有冇去到其他地方，例如背脊或者大髀？」 | Back → renal; groin → ureteric/hernia | Renal stone, inguinal hernia |
| Severity/progression | Getting better or worse? Score 1–10? | 「依家個痛係好緊定好番？1–10分你會畀幾多分？」 | Worsening → complication (perforation) | Perforated diverticulitis |
| Bowel habit | Any change in bowel habit? Blood/mucus in stool? | 「大便習慣有冇變？有冇血或者黏液？」 | Key red flag for colorectal cancer [1] | Sigmoid Ca, IBD, diverticular bleed |
| PR bleeding | Bright red blood per rectum? | 「有冇見到鮮血喺大便度？」 | Fresh blood → diverticular bleed, Ca, haemorrhoids | Diverticular bleeding, colorectal Ca |
| Fever | Any fever or chills? | 「有冇發燒或者打冷震？」 | Fever → diverticulitis, PID, abscess | Acute diverticulitis, PID |
| Urinary Sx | Pain on passing urine? Blood? Frequency? | 「小便有冇痛？有冇血？有冇去得密？」 | Dysuria → UTI; haematuria → renal stone; frequency → colovesical fistula | UTI, ureteric colic, diverticular fistula |
| LMP (♀) | When was your last period? Could you be pregnant? | 「你最後一次月經幾時嚟？有冇可能懷孕？」 | Must exclude ectopic pregnancy in any reproductive-age female with LLQ pain [1] | Ruptured ectopic pregnancy |
| Vaginal discharge/bleeding (♀) | Any abnormal discharge or bleeding? | 「有冇異常分泌物或者落紅？」 | Discharge + pain → PID; bleeding → ectopic | PID, ectopic pregnancy |
| Sexual Hx (♀) | Sexually active? Multiple partners? Contraception? | 「有冇性生活？有冇用安全套或避孕？」 | Risk factor for PID and ectopic | PID, ectopic pregnancy |
| Weight loss | Unintentional weight loss? | 「體重有冇輕咗？」 | Red flag for malignancy | Colorectal Ca |
| Appetite | Any loss of appetite? | 「胃口有冇差咗？」 | Constitutional symptom | Malignancy, IBD |
| Past surgical Hx | Any previous abdominal surgery? | 「以前有冇做過肚嘅手術？」 | Adhesions → obstruction; prior appendicectomy rules out appendicitis | Adhesion-related obstruction |
| Drug Hx | NSAIDs? Steroids? Antibiotics? Anticoagulants? | 「有冇食止痛藥、薄血丸或者抗生素？」 | NSAIDs mask fever; anticoagulants → haematoma; recent antibiotics → C. diff | Drug-related causes |
| FH | Family Hx of bowel cancer or IBD? | 「屋企人有冇腸癌或者炎症腸病？」 | ↑risk colorectal Ca, Crohn's, UC | Colorectal Ca, IBD |
| Social Hx | Smoking? Alcohol? Occupation? Stress? | 「有冇食煙飲酒？做咩工作？最近有冇壓力？」 | Smoking is RF for diverticulitis; stress → IBS | IBS, diverticulitis |
| Functional impact | How does this affect your daily life/work? | 「呢個痛有冇影響你返工或者日常生活？」 | Functional impact = social problem for biopsychosocial | Biopsychosocial formulation |
Case Report Form Answer Builder
- CC: LLQ pain × [duration]
- HPI must include: onset, character, severity, radiation, aggravating/relieving factors, associated Sx (fever, bowel habit change, PR bleeding, urinary Sx, gynae Sx), progression, red flags (weight loss, appetite)
- Likely examples: "Increasing LLQ pain not relieved by OTC analgesics"; "LLQ pain with change in bowel habit"; "LLQ pain with concern about bowel cancer"
- Phrase as the PATIENT's main reason — not the doctor's differential. E.g., "Patient presents for investigation of persistent LLQ pain affecting daily activities."
| Likely Content | Example Wording | |
|---|---|---|
| Ideas | "Patient thinks it might be related to the bowel / constipation / something serious" | "Patient thinks the pain may be caused by a bowel problem." |
| Concerns | "Worried about cancer because father had colon cancer" or "Worried about fertility" | "Patient is worried that this could be bowel cancer as a family member was recently diagnosed." |
| Expectations | "Wants investigation (e.g., colonoscopy/scan) or referral to specialist" | "Patient expects to have a scan or referral to rule out serious disease." |
- In patient > 50 with LLQ pain + low-grade fever + localised tenderness: Acute sigmoid diverticulitis [1][2]
- Minimum supporting evidence: LLQ tenderness, low-grade fever, altered bowel habit, age > 50
- In reproductive-age ♀ with missed period: Must consider ectopic pregnancy first
- In younger patient with chronic crampy pain + no red flags: IBS
| DDx | Key Discriminator |
|---|---|
| 1. Colorectal (sigmoid) carcinoma | Change in bowel habit, weight loss, PR bleeding, age > 50, FH |
| 2. Ovarian pathology (torsion/cyst) / Ectopic pregnancy (if ♀) | Sudden onset, missed period, adnexal mass/tenderness |
| 3. Ureteric colic | Colicky loin-to-groin pain, haematuria, restless patient |
| Domain | Problem |
|---|---|
| Biological | Acute diverticulitis requiring antibiotics ± CT confirmation; need to exclude colorectal Ca |
| Psychological | Anxiety about cancer (especially if FH or persistent symptoms) |
| Social | Pain affecting work productivity / inability to carry out daily activities / dietary impact |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports |
|---|---|---|---|
| Acute diverticulitis (most likely) | LLQ tenderness ± localised guarding ± palpable tender mass (phlegmon) [2] | Gentle palpation of LLQ with patient supine, knees bent | Localised peritoneal inflammation over sigmoid colon; mass = phlegmon/abscess |
| Colorectal Ca | Palpable LLQ mass (hard, irregular, non-tender) | Deep palpation of LLQ | Fixed hard mass suggests malignancy |
| Ectopic pregnancy (♀) | Cervical motion tenderness (chandelier sign) + adnexal tenderness | Bimanual pelvic examination | Pain on cervical excitation = peritoneal irritation from ectopic |
| Ovarian torsion | Unilateral adnexal tenderness ± palpable adnexal mass | Bimanual pelvic examination | Enlarged tender ovary |
| Ureteric colic | Loin tenderness (renal angle tenderness) | Percuss renal angle with fist | Pyeloureteric irritation from stone; no reliable abdominal sign in brief FM station — urine dipstick for haematuria is the best bedside clue |
| PID | Bilateral lower abdominal tenderness + cervical motion tenderness + purulent cervical discharge | Speculum then bimanual examination | Cervical motion tenderness = hallmark of PID |
| IBS | No reliable physical sign — abdomen often non-tender or mildly tender without guarding; diagnosis of exclusion | — | Best exam clue: Rome IV criteria met + normal examination |
Must-Not-Miss Red Flags — Urgent Referral
- Peritonism (guarding, rigidity, rebound) → surgical emergency (perforation, ruptured ectopic)
- Haemodynamic instability (tachycardia, hypotension) → ruptured ectopic, massive diverticular bleed
- Missed period + LLQ pain in reproductive-age ♀ → always do urine pregnancy test before anything else
- Weight loss + change in bowel habit + PR bleeding in > 50 → urgent colonoscopy to exclude colorectal Ca
- Irreducible tender groin lump → strangulated hernia, needs emergency surgery
Top traps that lose marks:
- ❌ Forgetting to ask LMP / pregnancy status in a female patient — this is the #1 exam pitfall for lower abdominal pain
- ❌ Not asking about bowel habit change and PR bleeding — misses colorectal Ca
- ❌ Diagnosing IBS without excluding red flags first — IBS is a diagnosis of exclusion
- ❌ Confusing diverticulitis (LLQ) with appendicitis (RLQ) — know the anatomy
- ❌ Not asking ICE — dedicated marks lost
- ❌ Not examining the groin — hernia is listed as a DDx on the GC slide [1]
Shortest safe management/safety-net line:
「如果你突然痛得好勁、發高燒、暈低、或者大便有大量血，請即刻去急症室。」 (If you get sudden severe pain, high fever, dizziness, or heavy bleeding, go to A&E immediately.)
High Yield Summary
What to ASK: SOCRATES for pain → bowel habit/PR bleeding → urinary Sx → LMP + gynae Hx (♀) → fever → weight loss → FH bowel Ca → ICE + hidden agenda
What to WRITE: CC = LLQ pain × duration; Most likely Dx = acute diverticulitis (if > 50 + fever + LLQ tenderness) or consider ectopic/ovarian pathology in young ♀; DDx = sigmoid Ca, ovarian pathology/ectopic, ureteric colic; Biopsychosocial = biological (need abx/investigation), psychological (cancer anxiety), social (functional impact)
What NOT to MISS: Pregnancy test in ♀, peritonism, PR bleeding + weight loss (Ca), irreducible hernia; GC 195 slide list of LLQ DDx is high yield [1]
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 195. Lower and diffuse abdominal pain RLQ problems; pelvic inflammatory disease; peritonitis and abdominal emergencies.pdf (p.6 — LLQ differential list) [2] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (p.643 — Diverticulitis clinical manifestation) [3] Senior notes: Maksim Surgery Notes.pdf (p.89 — Acute appendicitis and lower abdominal pain differentials) [4] Senior notes: Maksim Medicine Notes.pdf (p.119 — Clinical approach to abdominal pain) [5] Lecture slides: Clinical Demonstration_Abdomen.pdf (p.1 — Abdominal regions and history taking)
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