Family medicine
Lymphadenopathy
Lymphadenopathy is the abnormal enlargement of one or more lymph nodes, often indicating infection, inflammation, or malignancy.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Reactive viral lymphadenopathy (URTI, EBV) | Tender, < 2 weeks, preceding URTI, self-limiting [5][10] | 「最近有冇傷風感冒？」If tender + resolving → reactive |
| TB lymphadenitis | Painless, progressive, matted, ± cold abscess, cervical; HK is endemic [7] | 「有冇接觸過肺癆病人？有冇夜晚出汗、咳耐咗？」 | |
| Serious Not To Miss | Lymphoma (HL / NHL) | Painless, firm, rubbery, persistent > 4–6 weeks, ± B symptoms [1][2] | 「粒嘢痛唔痛？有冇發燒、夜晚出好多汗、瘦咗？」 |
| Acute leukaemia (ALL/AML) | Pancytopenia signs (pallor, bleeding, infection) + LAD + hepatosplenomegaly [6] | 「有冇覺得攰、容易瘀、或者經常發燒？」 | |
| Metastatic carcinoma / NPC | Hard, fixed, non-tender; supraclavicular (Virchow's node) [11]; HK: NPC common | 「耳仔有冇塞住、鼻有冇出血？」(NPC) | |
| HIV | Persistent generalised LAD ( ≥ 2 non-contiguous sites > 3–6 months) [9] | 「有冇新嘅性伴侶？有冇高風險行為？」 | |
| Pitfalls | Infectious mononucleosis (EBV) | Triad: fever + tonsillar pharyngitis + LAD; splenomegaly; atypical lymphocytes [5] | 「喉嚨好痛？肚有冇脹？」Ampicillin rash is classic trap [12] |
| Kikuchi disease | Young Asian female, fever, tender cervical LAD, neutropenia; self-limiting [10] | 「你係後生女仔，有冇持續發燒同頸粒嘢痛？」 | |
| Toxoplasmosis | Cat exposure, immunocompromised; cervical LAD [10] | 「有冇養貓？有冇食未煮熟嘅肉？」 | |
| Masquerades | Drug-induced LAD / DRESS | New drug in past weeks-months (phenytoin, carbamazepine); ± fever, rash, eosinophilia [4] | 「最近有冇開始食新嘅藥？有冇出疹發燒？」 |
| SLE / Autoimmune | Young female, rash, joint pain, oral ulcers, LAD; anti-dsDNA+ [8] | 「有冇面紅疹、關節痛、口瘡？」 | |
| Trying to Tell Me Something? | Cancer anxiety / Health anxiety | Recent bereavement from cancer; media scare; persistent worry disproportionate to finding | 「你最擔心係咩？有冇屋企人試過類似嘅嘢？」 |
Lymphadenopathy — 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，今日由我同你傾下。你點稱呼？」「今日嚟睇醫生，最主要係咩事呢？」 | Warm greeting + open question = interpersonal marks. Establishes rapport instantly. |
| 0:30–1:30 | HPI: characterise the lymphadenopathy | 「呢粒嘢幾時開始㗎？」「有冇大過？」「痛唔痛㗎？」「有冇其他地方都有腫㗎？」「有冇發燒、夜晚出好多汗、或者瘦咗好多？」 | Covers onset, progression, pain, distribution, and B symptoms — the key discriminators for malignancy. |
| 1:30–2:30 | Red flags + targeted systems review | 「有冇咳或者氣促？」「有冇周身痕或者出疹？」「最近有冇覺得特別攰或者面青？」「有冇牙肉出血、容易瘀？」「食嘢吞嘢有冇困難？」 | Screens for serious causes: lymphoma, leukaemia, TB, HIV, head & neck cancer. |
| 2:30–3:30 | PMH, DHx, FHx, social Hx, sexual Hx | 「之前有冇長期病？」「有冇食緊咩藥？」「有冇藥物敏感？」「屋企人有冇癌症或者血液病？」「你做咩工作？有冇養貓？」「有冇去過旅行？」「唔好意思問多句，有冇新嘅性伴侶？」 | Drug causes (phenytoin, carbamazepine), TB contacts, HIV risk, toxoplasmosis (cats), travel (tropical infections). |
| 3:30–4:30 | ICE — uncover the hidden agenda | 「你自己覺得呢粒嘢係咩嚟㗎？」(Idea) 「你最擔心啲咩？」(Concern) 「你嚟睇醫生最希望我幫到你啲咩？」(Expectation) | ICE is directly tested on the CRF. The hidden agenda is often cancer fear triggered by a relative's cancer or persistent lump. Probe: 「有冇咩令你特別擔心先嚟睇？」 |
| 4:30–5:15 | Summarise, signpost, suggest plan | 「等我總結一下你講嘅嘢…」「我想幫你檢查下呢粒嘢，同埋可能需要抽血睇下，ok唔ok？」 | Summarising shows active listening. Signposting the plan scores marks. |
| 5:15–6:00 | Safety net + empathic close | 「我明白你擔心，我哋會盡快搞清楚。如果之間有發燒、出血、或者突然大好多，要即刻返嚟睇。」「你仲有冇嘢想問？」 | Safety net covers red flags. Checking understanding + warm closing = extra interpersonal marks. |
Uncovering the hidden agenda: The symptom is the lump, but the RFC is often fear of cancer (e.g., a friend/relative had lymphoma). Ask 「點解今日先嚟？係咪有啲嘢令你特別擔心？」 early in ICE to unlock this.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did you first notice it? | 「幾時開始發現㗎？」 | < 2 weeks → likely reactive; > 4-6 weeks persistent → biopsy needed [1] | Reactive vs malignant |
| Progression | Has it been growing? | 「有冇越嚟越大？」 | Progressive enlargement without infection = red flag | Lymphoma, metastatic CA |
| Pain/Tenderness | Is it painful? | 「痛唔痛？」 | Painless, firm, rubbery → malignancy; tender → infection/reactive [1][2] | Painless = lymphoma; tender = infection |
| Site & number | Where exactly? Any others? | 「喺邊度？其他位有冇？」 | Generalised ( ≥ 2 non-contiguous sites) vs localised [1] | Generalised → systemic cause (HIV, SLE, lymphoma) |
| Size | How big is it? | 「大概幾大？」 | > 1 cm generally significant; > 1.5 cm jugulodigastric; > 2 cm supraclavicular always investigate [3] | Malignancy if large, hard, fixed |
| B symptoms | Fever? Night sweats? Weight loss? | 「有冇發燒？夜晚瞓覺出好多汗？瘦咗幾多？」 | B symptoms = fever > 38°C, unexplained > 10% weight loss/6mo, drenching night sweats [1][2] | Lymphoma (HL/NHL), TB, HIV |
| Skin/rash | Any rash or itching? | 「有冇出疹或者周身痕？」 | Pruritus a/w HL; rash a/w viral, SLE, drug reaction (DRESS) [4] | HL, DRESS, SLE, viral |
| URTI symptoms | Sore throat? Runny nose recently? | 「最近有冇喉嚨痛、傷風？」 | Preceding viral URTI → reactive lymphadenopathy; pharyngitis + LAD + splenomegaly → EBV infectious mononucleosis [5] | Reactive, EBV/IM |
| Bleeding/Bruising | Easy bruising? Bleeding gums? | 「容唔容易瘀？牙肉有冇出血？」 | Marrow failure signs → leukaemia [6] | ALL, AML |
| Fatigue/Pallor | Very tired? | 「覺唔覺得好攰？面色有冇差咗？」 | Anaemia from marrow infiltration or chronic disease | Leukaemia, lymphoma, HIV |
| Swallowing/Breathing | Trouble swallowing or breathing? | 「吞嘢或者呼吸有冇困難？」 | Mediastinal mass → airway compression [6] | T-ALL, HL mediastinal mass |
| PMH | Any chronic disease? TB contact? | 「有冇長期病？有冇接觸過肺癆病人？」 | TB lymphadenitis = 2nd most common extrapulmonary TB [7]; autoimmune diseases (SLE, Sjögren's) [8] | TB, SLE, Sjögren's |
| Drug Hx | Any medications? | 「食緊咩藥？」 | Phenytoin, carbamazepine, allopurinol → drug-induced LAD; DRESS [4] | Drug-induced LAD, DRESS |
| Allergy | Drug allergies? | 「有冇藥物敏感？」 | Standard safety question | DRESS if recent new drug |
| Family Hx | Anyone in family had cancer or blood disease? | 「屋企人有冇癌症或者血液病？」 | Triggers patient's fear (hidden agenda); familial cancer syndromes | Hidden agenda exploration |
| Social/Occupation | Job? Travel? Pets (cats)? | 「做咩工㗎？最近有冇去旅行？有冇養貓？」 | Cat → toxoplasmosis; travel → tropical infection; occupational exposures [7] | Toxoplasmosis, travel-related infection |
| Sexual Hx | New sexual partners? | 「唔好意思，最近有冇新嘅性伴侶？有冇安全措施？」 | HIV: unexplained generalised LAD is a non-AIDS-defining feature — offer HIV test [9] | HIV, syphilis, STIs |
| Smoking/Alcohol | Smoking? Alcohol? | 「有冇食煙飲酒？」 | Smoking → head & neck CA; alcohol-induced pain → classic HL sign [2] | NPC, HL |
| Functional impact | Affecting daily life? Work? Sleep? | 「影唔影響返工或者瞓覺？」 | Captures psychosocial dimension for CRF | Biopsychosocial framing |
Case Report Form Answer Builder
- CC: "Neck lump for [duration]" or "Swelling in [location] for [duration]"
- HPI high-yield points: Site, size, onset, duration, progression, pain/tenderness, number (single vs multiple), distribution (localised vs generalised), associated B symptoms (fever, night sweats, weight loss), preceding infection (URTI/sore throat), skin changes, functional impact, and any previous similar episodes.
- Likely examples: "Worried the neck lump might be cancer", "The lump has not gone away after 4 weeks", "Advised by friend/family to see doctor about persistent lump"
- Choose the patient's own stated reason — this is often fear-driven, not purely symptom-driven. Phrase it as one sentence: "Patient is worried about possibility of cancer due to persistent painless neck lump."
| Likely Content | Example Wording for CRF | |
|---|---|---|
| Idea | "I think it might be cancer / infection / something serious" | Patient thinks the lump may be a tumour because it has been growing. |
| Concern | "I'm afraid it's lymphoma — my uncle died of it" | Patient is worried about lymphoma as family member had similar disease. |
| Expectation | "I want a blood test / scan / biopsy / reassurance" | Patient expects referral for further investigation to rule out malignancy. |
- In a young patient with tender LAD + recent URTI/sore throat: Reactive viral lymphadenopathy or Infectious mononucleosis (if triad present)
- In a patient with painless, persistent > 4 weeks, firm/rubbery LAD ± B symptoms: Lymphoma
- In HK endemic setting with chronic painless cervical LAD ± cold abscess: TB lymphadenitis
- Minimum supporting evidence: Duration, character (painless/firm/rubbery vs tender/soft), distribution, presence or absence of B symptoms, preceding illness.
| DDx | Key Discriminator |
|---|---|
| 1. Lymphoma (HL or NHL) | Painless, firm, rubbery, persistent, ± B symptoms, ± splenomegaly [1][2] |
| 2. TB lymphadenitis | Chronic, matted, cervical, ± cold abscess; endemic in HK [7] |
| 3. Infectious mononucleosis (EBV) | Fever + pharyngitis + LAD + splenomegaly + atypical lymphocytes; young patient [5][12] |
(Swap in HIV, leukaemia, metastatic CA, or drug-induced LAD depending on the stem)
| Domain | Problem |
|---|---|
| Biological | Persistent lymphadenopathy requiring investigation to exclude malignancy (lymphoma/TB) |
| Psychological | Anxiety/fear about cancer diagnosis; sleep disturbance from worry |
| Social | Functional impairment — unable to concentrate at work/school; impact on family (e.g., parents worried) |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Reactive viral LAD | Tender, mobile, soft, < 1 cm cervical LN with inflamed pharynx | Palpate cervical chain; inspect oropharynx | Soft, tender, mobile LN + pharyngitis = reactive/infective cause |
| Lymphoma | Painless, firm/rubbery, non-tender, > 2 cm LN ± splenomegaly | Systematic lymphoid survey (cervical → supraclavicular → axillary → epitrochlear → inguinal) + palpate for splenomegaly [3] | Firm, rubbery, fixed, non-tender LN persisting > 4 weeks is classic lymphoma presentation |
| TB lymphadenitis | Matted, non-tender cervical LN ± overlying skin erythema/sinus | Palpate cervical chain for matting and fixation to surrounding tissues | Matted nodes + cold abscess in cervical region is hallmark of TB LAD [7] |
| Infectious mononucleosis | Bilateral posterior cervical LAD + tonsillar exudates + splenomegaly | Palpate posterior cervical/auricular LN; inspect tonsils; palpate spleen | Triad of fever + tonsillar pharyngitis + LAD; splenomegaly in 50–60% [5][12] |
| Leukaemia (ALL) | Hepatosplenomegaly + petechiae/bruising + pallor | Palpate liver/spleen; inspect skin for petechiae/ecchymosis | Marrow failure signs (anaemia, bleeding, infection) + LAD + hepatosplenomegaly = ALL [6] |
| HIV | Persistent generalised LAD ( ≥ 2 non-contiguous sites) ± oral candidiasis | Full lymphoid survey; inspect oral cavity | Generalised LAD > 3–6 months without alternative explanation = consider HIV [9] |
| Metastatic CA (NPC) | Hard, fixed, non-tender supraclavicular or upper cervical LN | Palpate LN; assess mobility and consistency | Hard, fixed LN = suspicious for metastasis; left supraclavicular (Virchow's) → GI malignancy [11] |
Must-Not-Miss Red Flags — Refer Urgently
- Painless, firm/rubbery LN persisting > 4–6 weeks → excisional/core biopsy (FNA alone is NOT adequate for lymphoma diagnosis!) [1][2]
- Supraclavicular lymphadenopathy at any age = always investigate (high malignancy risk) [3]
- B symptoms (fever > 38°C, weight loss > 10%/6mo, drenching night sweats) → urgent haematology referral [1]
- Pancytopenia signs (pallor + bleeding + recurrent infection) → urgent CBC + blood film → haematology [6]
- Rapidly enlarging mass with compression symptoms (stridor, SVCO, dysphagia) → emergency referral
- Unexplained generalised LAD → always offer HIV test [9]
Top traps that lose marks:
- Forgetting to ask about B symptoms — this is the single most important differentiator between reactive and malignant LAD.
- Not asking sexual history / HIV risk — students lose marks by avoiding this; use a polite Cantonese opener: 「唔好意思問一個比較私人嘅問題…」
- Writing "infection" as the sole diagnosis when LAD is persistent > 4 weeks — examiners expect you to consider malignancy.
- Missing drug history — phenytoin, carbamazepine → pseudo-lymphoma / LAD; DRESS can present with LAD + fever + rash [4].
- Not doing a full lymphoid survey on physical exam — you must mention checking ALL lymph node groups + liver/spleen.
- Stating FNA as adequate for lymphoma diagnosis — excisional biopsy or core biopsy is required for lymphoma; FNA is NOT sufficient [1][2].
- Forgetting ICE — ICE is directly marked on the CRF; cancer anxiety is the most common hidden concern.
Shortest safe management/safety-net line: 「我會幫你安排抽血同照超聲波，如果有需要會轉介你做活檢。如果等緊期間有發燒、出血、或者粒嘢突然大好多，要即刻返嚟。」
High Yield Summary
What to ASK: Onset/duration, pain, progression, distribution (localised vs generalised), B symptoms (fever/night sweats/weight loss), preceding infection, drug history, sexual/HIV risk, TB contact, cat exposure, family cancer history, ICE.
What to WRITE on the CRF:
- CC: "Neck lump × [duration]"
- RFC: Usually cancer fear / persistent lump
- ICE: Fear of cancer; wants investigation/reassurance
- Most likely Dx: Reactive viral LAD (if acute + tender) OR Lymphoma (if persistent + painless + B symptoms) OR TB LAD (if chronic + matted + HK setting)
- DDx: Lymphoma, TB LAD, EBV/IM, HIV, leukaemia, metastatic CA, drug-induced LAD
- Biopsychosocial: Biological (LAD requiring investigation), Psychological (cancer anxiety), Social (work/school impact)
- Physical sign: Character of LN (firm/rubbery/painless → lymphoma; tender/soft/mobile → reactive; matted → TB) + hepatosplenomegaly
What NOT to MISS: B symptoms, supraclavicular node, HIV risk, drug causes, full lymphoid survey on exam, excisional biopsy (not FNA) for suspected lymphoma.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: Block A - Generalised Lymphadenopathy_ Differential diagnosis and principle of management.pdf [2] Senior notes: Maksim Medicine Notes.pdf (Lymphoma section, p.178) [3] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.1392 — LN size criteria; p.1422–1425 — lymphoma clinical features and diagnosis) [4] Senior notes: Block A - Fundamentals of Allergology.pdf (DRESS section, p.15) [5] Senior notes: Ryan Ho Respiratory.pdf (Infectious mononucleosis, p.53) [6] Lecture slides: GC 060. High white cell count.pdf (p.5 — clinical features of acute leukaemia) [7] Senior notes: Gen Clerk Anaes + Microbiology Summary.pdf (TB lymphadenitis, p.33); MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.159) [8] Senior notes: Ryan Ho Rheumatology.pdf (Sjögren's syndrome, p.88) [9] Lecture slides: GC 061. HIV positive_HIV related diseases, accidental needle prick injury.pdf (p.34 — non-AIDS-defining features; offer HIV test for unexplained generalised LAD) [10] Senior notes: Ryan Ho Haemtology.pdf (Kikuchi disease, Castleman disease, p.88); Ryan Ho Fundamentals.pdf (p.396) [11] Senior notes: Ryan Ho GI.pdf (Troisier's sign / Virchow's node, p.12) [12] Past papers: 2024 Fourth Summative MCQ.pdf (Q52 — infectious mononucleosis)
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.
Mouth Ulcers / Sore Tongue
Mouth ulcers are painful breaks in the oral mucosa, and a sore tongue (glossitis or glossodynia) refers to inflammation or pain of the tongue, both arising from causes such as trauma, nutritional deficiencies, infections, autoimmune conditions, or systemic diseases.