Others (In Murtagh)
Jaundice
Jaundice is the yellowish discoloration of the skin, sclera, and mucous membranes resulting from elevated serum bilirubin levels (hyperbilirubinemia) exceeding approximately 2–3 mg/dL.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Viral hepatitis (HBV acute flare / HAV / HEV) [9] | Acute onset, malaise, tea-coloured urine, ↑↑ALT > AST, +ve serology | 「最近有冇食過生蠔？有冇接觸過肝炎病人？」 | ~25% |
| Gallstone disease (choledocholithiasis) | Intermittent jaundice, RUQ colicky pain, ± fever [3] | 「肚痛係咪一陣一陣，右上腹嗰度？」 | ~20% | |
| Alcoholic liver disease / MASLD [7] | Chronic heavy alcohol use or metabolic syndrome; AST > ALT (2:1 ratio in ALD) | 「你每日飲幾多酒？飲咗幾多年？」 | ~10% | |
| Serious Not To Miss | Malignant biliary obstruction (CA pancreas head, cholangiocarcinoma) [3][10] | Painless progressive jaundice + LOW/LOA + palpable GB (Courvoisier sign) | 「黃疸係咪越嚟越深？有冇瘦咗？肚有冇痛？」 | ~5% |
| HCC on background CLD | Known HBV carrier + LOW + hepatomegaly | 「你知唔知自己有冇乙肝帶菌？」 | ~3% | |
| Acute cholangitis | Charcot's triad: RUQ pain + fever + jaundice (surgical emergency) [4] | 「肚痛加發燒加黃疸，三樣一齊有冇？」 | ~2% | |
| Acute liver failure | Encephalopathy + coagulopathy (INR > 1.5) + jaundice; no prior liver disease | 「有冇意識模糊？有冇流牙血或者瘀傷？」 | < 1% | |
| Pitfalls | Drug-induced liver injury (DILI) | New drug/TCM in preceding weeks; ↑ALT | 「最近有冇食過新藥、中藥或者補品？」 | ~5% |
| Gilbert syndrome | Mild unconjugated hyperbilirubinaemia during fasting/illness; normal LFT otherwise | 「係咪每次攰或者唔食嘢先至黃？」 | ~3% | |
| Haemolytic anaemia | Lemon-yellow jaundice, normal-coloured urine (no bilirubinuria), dark stools, splenomegaly [2][11] | 「小便顏色正唔正常？有冇頭暈心跳？」 | ~2% | |
| Masquerades | Decompensated cirrhosis (any cause) | Ascites, spider naevi, palmar erythema, gynaecomastia | 「肚有冇脹大？」 | ~5% |
| Drugs (paracetamol OD, statins, anti-TB) | Temporal relationship to drug | 「有冇食過大量止痛藥？」 | ~5% | |
| Trying to Tell Me Something? | Fear of liver cancer / fear of contagion to family / worry about alcohol dependency / work/financial stress | Hidden agenda: "my father died of liver cancer" | 「你最擔心係咩嘢？有冇嘢想同我講多啲？」 | ~10% |
Exam framing for Jaundice in FM: The patient is most likely an adult presenting with new-onset jaundice in a primary care setting. Think viral hepatitis (HBV/HAV/HEV high prevalence in HK), alcoholic/MASLD liver disease, drug-induced hepatitis, gallstone disease, or malignancy. A neonatal/paediatric scenario is less likely in GC clinical test Station 1 but know the key discriminators.
Minute-by-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, ID, set agenda | 「你好，我係X醫生。請問點稱呼你？今日有咩嘢想睇吓？」(Hello, I'm Dr X. How should I address you? What brings you in today?) | Rapport, interpersonal skill marks |
| 0:30–1:30 | Chief complaint + HPI – onset, duration, progression; urine/stool colour; pain; itch; fever; weight loss; appetite | 「你幾時開始發覺眼白/皮膚黃咗？」「有冇覺得小便好似普洱茶咁深色？大便有冇變淺色？」「有冇肚痛？痕唔痕？」 | Core symptom analysis; differentiates pre-hepatic/hepatic/post-hepatic |
| 1:30–2:30 | Red flags & systems review – bleeding, confusion, vomiting blood, abdominal swelling, LOW/LOA, night sweats | 「有冇試過嘔血、屙血？肚有冇脹起？有冇瘦咗？」 | Identifies serious disorders – liver failure, malignancy |
| 2:30–3:30 | PMH, DHx, Allergy, FHx, SHx – hepatitis B/C carrier, gallstones, alcohol, drugs (paracetamol, TCM, herbal), IVDA, tattoo, travel, raw seafood, sexual history, occupation | 「你有冇乙型肝炎帶菌？飲唔飲酒？飲幾多？有冇食中藥或者補品？最近有冇去過旅行或者食過生蠔？」 | Drug/alcohol/viral history crucial; TCM is a common HK pitfall |
| 3:30–4:30 | ICE – Ideas, Concerns, Expectations | 「你自己覺得黃咗係咩原因？（Ideas）你最擔心啲咩？（Concerns）你今日嚟睇醫生最希望我幫到你啲乜？（Expectations）」 | Marks directly awarded for eliciting ICE |
| 4:30–5:15 | Uncover hidden agenda / RFC | 「除咗呢個問題之外，仲有冇其他嘢想同我講？」「點解揀今日嚟睇？係咪有啲嘢特別擔心？」 | "Why today?" reveals true RFC – e.g. fear of liver cancer, relative just diagnosed |
| 5:15–5:45 | Summarise & check understanding | 「等我總結吓：你大約X日前開始發覺皮膚黃咗，小便深色…我講得啱唔啱？」 | Shows active listening; interpersonal marks |
| 5:45–6:00 | Plan, safety-net, close | 「我建議今日幫你抽血驗吓肝功能同做個腹部超聲波。如果你有嘔血、意識模糊、肚好痛，就要即刻去急症室。」「你有冇嘢想問？」 | Safe closure; red-flag safety net |
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset/Duration | When did you first notice the yellow colour? | 「你幾時開始發覺自己黃咗？」 | Acute vs chronic aetiology | Acute → hepatitis, stone; chronic → CLD, malignancy |
| Urine colour | Has your urine become dark/tea-coloured? | 「小便有冇變深色，好似普洱茶咁？」 | Tea-coloured urine = conjugated hyperbilirubinaemia (cholestasis) [1][2] | Hepatic or post-hepatic cause |
| Stool colour | Have your stools become pale or clay-coloured? | 「大便有冇變淺色、好似白陶泥咁？」 | Pale stool = obstructive jaundice [2] | Gallstone CBD obstruction, malignant biliary obstruction |
| Pruritus | Do you feel itchy all over? | 「全身有冇好痕？有冇搲到損晒？」 | Pruritus ± scratch marks = post-hepatic (obstructive) jaundice [2] | Cholestasis – PBC, stone, tumour |
| Pain | Any abdominal pain? Where? | 「肚有冇痛？邊度痛？」 | RUQ pain → stone/cholecystitis; painless → malignant biliary obstruction (MBO) [3] | Painful = stone; painless progressive = malignancy |
| Fever/Rigors | Any fever or chills? | 「有冇發燒或者打冷震？」 | Charcot's triad (pain, fever, jaundice) = acute cholangitis [4] | Cholangitis – surgical emergency |
| Weight loss / LOA | Have you lost weight or appetite? | 「最近有冇瘦咗？食嘢點？」 | Constitutional Sx → malignancy | CA pancreas, cholangiocarcinoma, HCC |
| Bleeding | Any bleeding – gums, bruising, blood in stool/vomit? | 「有冇流牙血、瘀傷、嘔血或者屙黑便？」 | Coagulopathy → liver failure; ↑PT in jaundice = vit K malabsorption or liver failure [5] | Decompensated CLD, liver failure |
| Confusion/drowsiness | Any confusion or excessive sleepiness? | 「有冇覺得成日好攰、唔清醒、或者周圍嘅人話你反應慢咗？」 | Hepatic encephalopathy → liver failure [6] | Acute or acute-on-chronic liver failure |
| Alcohol | How much alcohol do you drink? Daily/weekly? | 「你飲唔飲酒？飲幾多？飲咗幾耐？」 | Alcoholic liver disease / alcoholic hepatitis [7] | ALD, MASLD if metabolic syndrome too |
| Drugs/TCM/Supplements | Taking any medications, Chinese medicine, or supplements? | 「有冇食緊藥？中藥？補品？止痛藥？」 | Drug-induced hepatitis – paracetamol, TCM, herbal very common in HK [2] | DILI |
| Hepatitis B/C | Are you a hepatitis B or C carrier? Any past hepatitis? | 「你有冇乙型肝炎帶菌？或者丙肝？之前有冇驗過？」 | HK prevalence of HBV ~7-8%; HBV is top cause of HCC [8] | Chronic HBV → cirrhosis → HCC |
| Raw seafood / Travel | Have you eaten raw shellfish/oysters recently? Any travel? | 「最近有冇食過生蠔或者生嘅海鮮？有冇去過旅行？」 | HAV/HEV from raw oysters [9] | Acute viral hepatitis A/E |
| Sexual / IVDA / Tattoo | Any new sexual partner, IV drug use, tattoo? | 「有冇新嘅性伴侶？有冇用過針筒？有冇紋身？」 | Parenteral/sexual transmission of HBV/HCV/HIV | Acute HBV, HCV |
| Family history | Any family member with liver disease or cancer? | 「屋企人有冇肝病或者肝癌？」 | Vertical HBV transmission; Wilson's, haemochromatosis | HBV-related CLD, Wilson's (young patient) |
| Occupation | What is your job? | 「你做咩工作㗎？」 | Occupational exposure; functional impact of illness | Healthcare worker (needlestick), construction (sick leave) |
| Functional impact | How does this affect your daily life/work? | 「呢個問題對你日常生活同工作有冇影響？」 | Biopsychosocial assessment | Social/functional problem for CRF |
Case Report Form Answer Builder
- CC: Jaundice (yellowish discolouration of skin/eyes) for [duration]
- HPI high-yield points to capture:
- Onset, duration, progressive vs intermittent
- Urine colour (tea-coloured → conjugated), stool colour (pale → obstructive)
- Associated: pruritus, pain (location, character), fever/rigors, weight loss, appetite
- Risk factors: alcohol, drugs/TCM, raw seafood, hepatitis B/C status, travel, sexual/IVDA history
- Red flags: confusion, bleeding, vomiting blood
- Examples: "Noticed yellow eyes for 1 week, worried about liver disease" / "Wife pointed out yellow skin, scared it might be cancer" / "GP found abnormal blood test"
- How to phrase: State the patient's own reason, not the medical diagnosis. E.g. "Patient noticed yellow skin and dark urine for 5 days, concerned about serious liver problem"
| Example Wording | |
|---|---|
| Ideas | "Patient thinks it may be related to alcohol / hepatitis B / the new Chinese medicine he started" |
| Concerns | "Worried about liver cancer because father died of it" / "Worried about infecting family" |
| Expectations | "Wants blood tests to check liver function" / "Wants referral to specialist" / "Wants to know if it is serious" |
- In an adult HK FM setting: Acute viral hepatitis (HAV/HBV flare) [9] or Gallstone-related obstructive jaundice – choose based on the stem:
- If raw seafood exposure + acute onset + ↑↑ALT → Acute hepatitis A/E
- If RUQ pain + fever + jaundice → Choledocholithiasis / cholangitis
- If painless progressive + weight loss → Malignant biliary obstruction
- If chronic alcohol → Alcoholic hepatitis/CLD
- Minimum supporting evidence: History features + one physical sign (see Q6)
| DDx | Key Discriminator |
|---|---|
| 1. Choledocholithiasis / cholangitis | RUQ colicky pain ± fever; intermittent jaundice; ↑↑ALP/GGT |
| 2. Drug-induced liver injury (DILI) | Temporal relation to new drug/TCM; ↑ALT |
| 3. Malignant biliary obstruction (CA pancreas / cholangioCA) | Painless progressive jaundice, weight loss, palpable GB (Courvoisier sign) [3][10] |
(Adjust list to the stem – always include at least one serious DDx)
| Domain | Problem |
|---|---|
| Biological | Underlying liver disease requiring investigation (LFT, viral serology, imaging) |
| Psychological |
References
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Menstrual cycle irregularity refers to variations in cycle length (oligomenorrhea > 35 days, polymenorrhea < 21 days) or unpredictable timing of menses, often reflecting underlying ovulatory dysfunction or hormonal imbalance.
Leg / Ankle Swelling
Leg or ankle swelling is the abnormal accumulation of fluid (edema) in the lower extremities, resulting from venous insufficiency, lymphatic obstruction, heart failure, hypoalbuminemia, or local inflammatory and musculoskeletal conditions.