LUQ Pain
Left upper quadrant pain is abdominal discomfort localized to the area overlying the spleen, stomach, splenic flexure of the colon, left kidney, and tail of the pancreas, commonly caused by splenic pathology, gastritis, pancreatitis, or colonic disorders.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Gastritis / PUD | Epigastric-LUQ burning/gnawing pain, relation to meals, NSAID/alcohol use [4] | 「食完嘢之後痛唔痛啲？有冇食止痛藥或飲酒？」 |
| Musculoskeletal (intercostal/chest wall) | Reproducible by palpation/movement | 「撳落去會唔會痛？」（tenderness on palpation） | |
| Serious Not To Miss | Splenic rupture/infarction | Sudden severe LUQ ± history of trauma, haematological disease, AF; Kehr's sign | 「最近有冇撞傷？有冇心房顫動或者血液病？」 |
| Acute pancreatitis | Epigastric→LUQ pain radiating to back, relieved by leaning forward, vomiting, alcohol/gallstone history [4] | 「痛有冇去到背脊？坐前啲會唔會舒服啲？」 | |
| Gastric/pancreatic malignancy | Weight loss, early satiety, anorexia, age > 45, FHx [3] | 「有冇瘦咗？食少少就飽？」 | |
| Ruptured AAA (if elderly) | Sudden severe abdominal/back/flank pain, pulsatile mass, hypotension [8] | 「突然好痛，有冇頭暈、標冷汗？」 | |
| Pitfalls | Left renal colic/pyelonephritis | Loin-to-groin colicky pain, haematuria, urinary symptoms [7] | 「痛有冇去到下面？小便有冇血或者刺痛？」 |
| Splenic flexure syndrome / constipation | Bloating, relief with flatus/bowel movement | 「放屁或者大完便會唔會舒服啲？」 | |
| Left lower lobe pneumonia (referred pain) | Cough, sputum, fever, pleuritic component | 「有冇咳？痛呼吸嘅時候會唔會差啲？」 | |
| Masquerades | Diabetic ketoacidosis | Diffuse abdominal pain, known DM, polyuria, vomiting [3] | 「你有冇糖尿病？最近飲水多唔多？」 |
| Herpes zoster (pre-rash) | Dermatomal burning/lancinating pain, preceding rash | 「有冇出過皮疹？痛係好似火燒咁？」 | |
| Depression/drugs (NSAIDs) | Low mood, functional pain, NSAID overuse | 「心情點？有冇食多咗止痛藥？」 | |
| Anxiety / fear of cancer | Recent exposure to cancer diagnosis in family/friend | 「你最擔心嘅係咩？有冇人病咗令你擔心？」 |
| 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。今日想了解下你嘅情況，方唔方便傾下？」（Hello, I'm Dr X. I'd like to understand your situation, is that OK?） | Patient-centred greeting; asks permission → interpersonal marks |
| 0:30–1:30 | Chief complaint + HPI (SOCRATES) | 「你邊度痛呀？幾時開始？痛嘅感覺係點樣？有冇去到其他位？食嘢之後會唔會嚴重咗？」 | Establishes site, onset, character, radiation, exacerbating/relieving factors — core HPI marks |
| 1:30–2:30 | Red flags + associated Sx | 「有冇嘔血或者屙黑便？有冇消瘦？有冇發燒？有冇撞傷過？」 | Must screen for serious causes (splenic pathology, pancreatitis, malignancy, AAA) |
| 2:30–3:30 | PMHx, DHx, allergy, FHx, social Hx | 「你本身有冇長期病？食緊咩藥？有冇藥物敏感？屋企人有冇試過類似？你飲唔飲酒？食唔食煙？」 | Alcohol → pancreatitis/gastritis; drugs (NSAIDs/aspirin) → PUD; family Hx → malignancy |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得係咩事呀？（Idea）你最擔心嘅係咩？（Concern）你今日嚟想我幫你做啲咩？（Expectation）」 | Directly examinable on CRF; scores interpersonal + CRF marks |
| 4:30–5:15 | Functional impact + psychosocial | 「呢個痛有冇影響到你返工、瞓覺或者食嘢？心情點呀？壓力大唔大？」 | Biopsychosocial problem identification; psychological screening |
| 5:15–6:00 | Summarise, signpost, safety net, close | 「等我總結返：你呢排左邊肚痛…我想幫你安排驗血同照超聲波。如果突然痛到好犀利、嘔血、頭暈，一定要即刻去急症室。你有冇其他想問？」 | Summarising demonstrates listening; safety net = must not miss; closing scores interpersonal marks |
Uncovering the hidden agenda: The simulated patient's main reason for consultation may not be the pain itself — it could be fear of cancer, worry after a relative's diagnosis, or stress. Use the ICE questions at 3:30 and genuinely explore what prompted today's visit: 「點解揀今日嚟睇呀？」（Why did you decide to come today?）
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site | Where exactly is the pain? | 「你隻手指住邊度痛？」 | LUQ maps to spleen, stomach, left kidney, pancreatic tail, splenic flexure [1] | Gastritis, splenic pathology, renal colic, pancreatitis |
| Onset | When did it start? Sudden or gradual? | 「幾時開始？突然定慢慢嚟？」 | Sudden → splenic rupture/infarct, renal colic; gradual → gastritis, splenomegaly | Sudden + severe = surgical emergency |
| Character | What does the pain feel like? | 「痛嘅感覺係點？脹痛、刺痛定絞痛？」 | Dull ache → splenomegaly/gastritis; colicky → renal/bowel; tearing → AAA [2] | Colicky = obstruction; constant = inflammation |
| Radiation | Does the pain go anywhere else? | 「有冇痛去到其他位，例如背脊、膊頭？」 | Back → pancreatitis, AAA; shoulder tip → splenic rupture (Kehr's sign) [1][2] | Shoulder tip = diaphragmatic irritation |
| Severity | How bad on a scale of 1-10? | 「如果10分最痛，你會畀幾多分？」 | Gauges urgency | Severe = consider urgent referral |
| Timing | Constant or comes and goes? Related to meals? | 「係成日痛定一陣陣？食完嘢之後有冇分別？」 | Post-meal → gastric ulcer; constant → malignancy/inflammation | Gastric ulcer worse with food [3] |
| Exacerbating | What makes it worse? | 「做咩嘢會痛啲？郁動、食嘢定飲酒？」 | Movement → peritonitis; alcohol → pancreatitis/gastritis | NSAIDs/alcohol = gastritis/PUD |
| Relieving | What makes it better? | 「做咩嘢會舒服啲？食胃藥、坐起身？」 | Antacids → PUD; lean forward → pancreatitis [4] | Lean forward relief is classic pancreatitis |
| Nausea/vomiting | Any nausea or vomiting? | 「有冇作嘔或者嘔？」 | Associated with pancreatitis, gastritis, renal colic | Repeated vomiting → pancreatitis/outlet obstruction [4] |
| GI bleeding | Any blood in vomit or black stool? | 「有冇嘔血或者屙黑便？」 | Red flag for upper GI bleed (PUD, gastric malignancy) | Coffee ground vomit = UGIB [5] |
| Weight loss | Any unintentional weight loss? | 「有冇無啦啦瘦咗？」 | Red flag for malignancy (gastric, pancreatic, lymphoma) | > 5% in 6 months = significant |
| Fever | Any fever or chills? | 「有冇發燒或者打冷震？」 | Splenic abscess, infected infarct, pancreatitis, perinephric abscess | Fever + LUQ = consider abscess/infective cause |
| Trauma | Any recent injury or accident? | 「最近有冇撞傷肚？」 | LUQ trauma → splenic injury (most commonly injured organ in blunt abdominal trauma) [6] | Delayed splenic rupture possible |
| Haematuria | Any blood in urine? | 「小便有冇血？」 | Renal stone is single most discriminating predictor with unilateral pain [7] | Renal/ureteric stone |
| Bowel habit | Any change in bowel habit? | 「大便習慣有冇改變？」 | Splenic flexure tumour, IBD | Alternating constipation/diarrhoea = colonic pathology |
| PMHx | Any previous illnesses? | 「你本身有咩病？」 | AF → splenic infarct; haematological disease → splenomegaly; PUD history | Myeloproliferative → massive splenomegaly |
| DHx | What medications are you taking? | 「食緊咩藥？有冇食止痛藥、薄血丸？」 | NSAIDs/aspirin → PUD/gastritis [4][5]; anticoagulants → splenic haemorrhage | NSAID + LUQ pain = think gastritis/PUD |
| Alcohol | How much alcohol do you drink? | 「你平時飲幾多酒？」 | Alcohol → acute/chronic pancreatitis, gastritis [4] | Heavy drinking = pancreatitis high on DDx |
| FHx | Any family history of GI cancer? | 「屋企人有冇人試過胃癌或者腸癌？」 | Red flag raising concern for malignancy | Gastric cancer, pancreatic cancer |
| Occupation/stress | What do you do? Any stress? | 「你做咩工作？最近壓力大唔大？」 | Stress → functional dyspepsia; occupation may explain trauma | Psychosocial contributor |
| Functional impact | How does this affect daily life? | 「呢個痛有冇影響到你日常生活？」 | Biopsychosocial assessment | Social/functional problem for CRF |
Case Report Form Answer Builder
Write: "LUQ pain for [duration], [character], [radiation], [aggravating/relieving factors], [associated symptoms]."
High-yield HPI points to capture:
- SOCRATES of the LUQ pain
- Meal relationship, NSAID/alcohol use
- Red flags: weight loss, GI bleeding, fever, trauma
- Relevant PMHx (AF, haematological disease, PUD, gallstones)
- Drug history (NSAIDs, aspirin, anticoagulants)
Examples (choose the best single answer from history):
- "To find out the cause of the LUQ pain"
- "Concerned about possible cancer after relative's diagnosis"
- "Pain affecting sleep and work — wants relief"
- "Wants investigation (e.g., scan) to exclude serious cause"
Write the patient's perspective, not your medical interpretation.
| Component | Likely Examples | Exact Wording for CRF |
|---|---|---|
| Ideas | "Patient thinks it may be a stomach ulcer / something wrong with spleen / cancer" | "Patient thinks the pain may be due to a stomach problem." |
| Concerns | "Worried it could be cancer / worried about needing surgery / worried about missing work" | "Patient is worried the pain may be caused by cancer." |
| Expectations | "Wants blood tests and scan / wants medication / wants referral to specialist" | "Patient expects investigation (ultrasound/blood tests) to find the cause." |
In a primary care FM setting with no red flags:
Most likely: Gastritis / Peptic ulcer disease
Minimum supporting evidence: LUQ/epigastric burning/gnawing pain, relation to meals, history of NSAID or alcohol use, tenderness on epigastric palpation, absence of red flags.
If the stem includes trauma → think splenic injury. If heavy alcohol + back radiation → think pancreatitis. Adjust accordingly.
| DDx | Key Discriminator |
|---|---|
| 1. Acute pancreatitis | Pain radiates to back, relieved by leaning forward, vomiting, alcohol/gallstone history |
| 2. Splenic pathology (infarction/enlargement) | History of haematological disease or AF, sudden onset, Kehr's sign |
| 3. Left renal colic | Colicky loin-to-groin pain, haematuria, urinary symptoms |
| Domain | Example |
|---|---|
| Biological | Possible gastritis/PUD requiring investigation (OGD, H. pylori test) and treatment |
| Psychological | Anxiety about possible serious diagnosis (e.g., cancer); sleep disturbance from pain |
| Social | Pain affecting work productivity / inability to perform job duties; dietary/alcohol impact |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Gastritis/PUD (most likely) | Epigastric/LUQ tenderness on palpation | Light then deep palpation of LUQ/epigastrium with patient supine, knees flexed | Localised tenderness without peritonism supports mucosal inflammation [1] |
| Acute pancreatitis | Epigastric tenderness with guarding ± Grey-Turner sign (flank ecchymosis) | Inspect flanks for bruising; palpate epigastrium | Epigastric tenderness + guarding in a patient with back-radiating pain and vomiting supports pancreatitis [4] |
| Splenic pathology | Palpable splenomegaly | Palpate from RIF towards LUQ on inspiration (Castell's or Middleton method); cannot get above it, moves with respiration, dull to percussion | Spleen must be ≥2× enlarged before palpable; enlarges along Gardner's line (10th rib → umbilicus → right ASIS) [1] |
| Left renal colic | Loin tenderness (renal angle tenderness) | Fist percussion at costo-vertebral angle | Tenderness suggests renal/ureteric pathology; haematuria on urinalysis is the single most discriminating predictor [7] |
| Ruptured AAA | Pulsatile, expansile abdominal mass | Palpate with both hands placed either side of the aorta in the epigastrium | Expansile (hands pushed apart) rather than just transmitted pulsation distinguishes AAA [8] |
Top Traps That Lose Marks
- Forgetting trauma history — Splenic rupture (including delayed rupture) is the most common organ injury in blunt abdominal trauma [6]. Always ask about trauma even if the patient doesn't volunteer it.
- Not asking about alcohol — Alcohol is the key discriminator for pancreatitis vs PUD in LUQ pain. Omitting it loses DDx marks.
- Confusing LUQ with epigastric — Gastric body/fundal ulcers and pancreatitis tail can present as LUQ. Don't dismiss PUD just because it's "not epigastric."
- Missing left lower lobe pneumonia — Referred pain to LUQ is a classic pitfall. Ask about cough, sputum, and pleuritic quality.
- Not screening for renal colic — Forgetting urinary symptoms and haematuria misses a common pitfall diagnosis.
- Writing the doctor's concern as the RFC — The RFC is the patient's reason. Write it from their perspective.
- Omitting ICE or only giving vague ICE — Be specific; marks are given for concrete ICE content.
Must-Not-Miss Red Flags → Urgent Referral:
- Haemodynamic instability (tachycardia, hypotension) → think splenic rupture, ruptured AAA
- Peritonism (guarding, rigidity, rebound) → surgical emergency
- GI bleeding (haematemesis, melaena) → urgent OGD
- Severe pain out of proportion to findings → mesenteric ischaemia [4]
- Fever + LUQ mass → splenic abscess
Safety-Net Line (for closing the station):
「如果你突然痛到好犀利、肚硬曬、嘔血、屙黑便、暈曬，一定要即刻去急症室。」 ("If you suddenly get very severe pain, rigid abdomen, vomiting blood, passing black stool, or feeling faint, go to A&E immediately.")
High Yield Summary
What to ASK: SOCRATES for LUQ pain; meal relationship; NSAID/alcohol/drug history; trauma; urinary symptoms; red flags (weight loss, GI bleeding, fever); ICE; functional impact; psychosocial stress.
What to WRITE on CRF: Chief complaint with full SOCRATES; RFC from patient's perspective; specific ICE; most likely Dx = gastritis/PUD (unless red flags point elsewhere); DDx = pancreatitis, splenic pathology, renal colic; biopsychosocial problems covering all three domains; physical sign = epigastric/LUQ tenderness.
What NOT TO MISS: Splenic rupture (ask trauma), pancreatitis (ask alcohol + back radiation), referred pain from left lower lobe pneumonia (ask cough), renal colic (ask haematuria), mesenteric ischaemia (pain out of proportion), and the patient's hidden concern (cancer fear, family stress).
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: Clinical Demonstration_Abdomen.pdf (Surface anatomy, spleen palpation, abdominal history framework) [2] Senior notes: Ryan Ho Fundamentals.pdf (p276 — abdominal pain radiation patterns) [3] Senior notes: Maksim Medicine Notes.pdf (p119 — abdominal pain DDx, red flags) [4] Senior notes: Block A - Upper abdominal pain_ peptic ulcer; pancreatitis and gallstone.pdf (p6 — epigastric pain DDx, pancreatitis features) [5] Senior notes: Block A - Gastroenterology Interactive Tutorial.pdf (p1 — UGIB approach, drug history) [6] Senior notes: Maksim Surgery Notes.pdf (p42 — abdominal trauma, spleen most commonly injured) [7] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (p792 — renal colic, haematuria as discriminator) [8] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (p912 — AAA clinical features)
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.
Lymphadenopathy
Lymphadenopathy is the abnormal enlargement of one or more lymph nodes, often indicating infection, inflammation, or malignancy.