RUQ Pain
Right upper quadrant pain is abdominal pain localized beneath the right costal margin, most commonly associated with hepatobiliary or gallbladder pathology such as cholecystitis or cholelithiasis.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Biliary colic | RUQ pain after fatty meal, lasts < 6h, no fever, self-limiting [1][2] | 「食完肥嘢之後痛，痛幾個鐘頭自己好返？」 | ~25% |
| Acute cholecystitis | RUQ pain > 4–6h, fever, positive Murphy's sign [1][2] | 「我㩒呢度你吸氣嗰陣會唔會痛到停咗？」(Murphy's sign) | ~15% | |
| Serious Not To Miss | Acute cholangitis | Charcot's triad: RUQ pain + fever + jaundice; Reynold's pentad adds hypotension + confusion [1][3] | 「有冇發燒加眼黃加肚痛一齊出現？」 | ~2% |
| Gallstone pancreatitis | Epigastric pain radiating to back, relieved leaning forward, ↑amylase [4] | 「痛有冇去到成條背脊？坐前傾會唔會舒服啲？」 | ~1% | |
| Hepatocellular carcinoma (HCC) | HBV carrier, weight loss, hard hepatomegaly, ↑AFP | 「你有冇乙型肝炎？肝有冇摸到硬嘢？」 | ~1% | |
| Cholangiocarcinoma / Pancreatic head CA | Painless progressive jaundice, weight loss, Courvoisier's sign | 「黃疸有冇越嚟越深？有冇消瘦？」 | ~1% | |
| Pitfalls | Peptic ulcer disease | Epigastric burning, relation to meals, NSAID/H. pylori | 「食嘢之後痛定肚餓嗰陣痛？有冇食止痛藥？」 | ~10% |
| Hepatitis (acute) | Dull ache from liver capsule distension, ↑ALT/AST, prodromal illness [5] | 「之前有冇似感冒？有冇食生嘢？」 | ~5% | |
| Renal colic (right) | Loin-to-groin pain, haematuria | 「痛有冇去到腰嗰度落去下面？小便有冇血？」 | ~5% | |
| Right lower lobe pneumonia | Cough, fever, pleuritic pain referred to RUQ | 「有冇咳？呼吸嗰陣痛唔痛？」 | ~2% | |
| Masquerades | Myocardial infarction (inferior) | Epigastric pain, nausea, risk factors, ECG changes | 「你有冇心臟病？痛嗰陣有冇胸口翳悶？」 | ~2% |
| Diabetic ketoacidosis | DM, vomiting, abdominal pain, Kussmaul breathing [4] | 「你有冇糖尿病？最近血糖有冇高咗？」 | < 1% | |
| Trying to Tell Me Something? | Anxiety / health anxiety / work stress | Fear of cancer, family member recently diagnosed | 「你最擔心係咩？屋企有冇人最近唔舒服？」 | ~10% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, open question | 「你好，我係今日嘅醫生。請問點稱呼你？今日有咩唔舒服呀？」(Hello, I'm today's doctor. How should I address you? What's bothering you today?) | Friendly opening; patient-centred; sets tone for interpersonal marks |
| 0:30–1:30 | HPI — SOCRATES for RUQ pain | 「呢個痛係幾時開始？痛喺邊度？有冇去到其他地方？係點樣痛法？有幾痛呀，1到10分？」 | Systematic pain analysis; captures chief complaint accurately |
| 1:30–2:30 | Associated symptoms & red flags | 「有冇發燒？有冇眼黃/皮膚黃？大便有冇變白色？小便有冇好深色？有冇嘔？有冇消瘦？食嘢點呀？」 | Screens for Charcot's triad (cholangitis), obstructive jaundice, malignancy |
| 2:30–3:30 | PMHx, DHx, allergy, FHx, social Hx | 「你以前有冇乜嘢病？食緊咩藥？有冇對藥物敏感？屋企人有冇膽石或者肝病？你飲唔飲酒？食嘢鍾唔鍾意食肥嘢？」 | Drug Hx (OCP, fibrates); alcohol (pancreatitis, liver); family Hx gallstone; diet (fatty food trigger) |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得呢個痛係咩原因呢？（Idea）你最擔心啲乜嘢？（Concern）你嚟睇醫生最希望我幫到你啲咩？（Expectation）」 | Directly scores ICE marks; uncovers hidden agenda (e.g. fear of cancer, wants scan, work impact) |
| 4:30–5:15 | Functional impact + psychosocial | 「呢個痛有冇影響你返工/瞓覺/食嘢？你最近心情點呀？壓力大唔大？」 | Biopsychosocial completeness; picks up psychological/social problems |
| 5:15–6:00 | Signpost, summarise, safety net, close | 「等我總結吓：你右邊肚痛咗X日，有發燒/冇發燒…我初步懷疑可能係膽嘅問題。如果痛得好犀利、發高燒、或者眼黃，一定要即刻去急症。你有冇其他問題想問？」 | Summarising shows active listening; safety-net phrase is mandatory for marks; checking understanding |
Uncovering the hidden agenda: Always ask 「其實你今日嚟，最主要係擔心啲咩？」 — the patient may have come because a relative had gallbladder cancer, or they want a specific test, not just pain relief.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Site | Where exactly is the pain? | 「痛喺邊度？可唔可以指俾我睇？」 | Localises to RUQ vs epigastric | RUQ → biliary; epigastric → PUD/pancreatitis |
| Onset | When did it start? Sudden or gradual? | 「幾時開始痛？係突然間定慢慢嚟？」 | Sudden → colic/cholecystitis; gradual → hepatitis | Acute cholecystitis, biliary colic |
| Character | What does the pain feel like? | 「係點樣痛法？脹住痛、絞住痛、定鈍痛？」 | Constant dull → cholecystitis; colicky → stone; burning → PUD | Biliary colic vs cholecystitis vs PUD |
| Radiation | Does the pain go anywhere else? | 「痛有冇去到其他地方？例如背脊？右邊膊頭？」 | Back → pancreatitis; right scapula (Boas sign) → cholecystitis [1] | Pancreatitis, cholecystitis |
| Duration | How long does each episode last? | 「每次痛幾耐？過唔過六個鐘頭？」 | ≤6h → biliary colic; > 4–6h → acute cholecystitis [1][2] | Key discriminator biliary colic vs cholecystitis |
| Severity | Pain score 1–10? | 「1到10分，你覺得幾痛？」 | Documents severity for triage | Severe → cholecystitis, pancreatitis |
| Fatty food | Does it come on after fatty meals? | 「食完肥嘢或者大餐之後有冇痛啲？」 | Fat intolerance → gallstone disease [2] | Biliary colic |
| Fever | Any fever or chills? | 「有冇發燒？有冇打冷震？」 | Fever → cholecystitis/cholangitis [1] | Charcot's triad |
| Jaundice | Any yellow eyes/skin, pale stool, dark urine? | 「眼白有冇變黃？大便有冇變白？小便有冇好深色好似濃茶咁？」 | Obstructive jaundice → CBD stone, cholangitis, malignancy [1][3] | Choledocholithiasis, cholangitis, pancreatic head CA |
| Nausea/vomiting | Any nausea or vomiting? | 「有冇作嘔或者嘔？」 | Common with biliary and pancreatic pathology | Biliary colic, pancreatitis |
| Weight loss | Any unintentional weight loss? | 「體重有冇無啦啦輕咗？」 | Red flag for malignancy | Pancreatic CA, cholangiocarcinoma, HCC |
| Alcohol | How much alcohol do you drink? | 「你飲唔飲酒？一個禮拜飲幾多？」 | Alcohol → pancreatitis, hepatitis, liver disease | Alcoholic pancreatitis, alcoholic hepatitis |
| Drug Hx | Any medications? OCP? NSAIDs? | 「食緊咩藥？有冇食避孕藥？有冇食止痛藥？」 | OCP → gallstone risk [2]; NSAIDs → PUD | Gallstone, PUD |
| Allergy | Any drug allergies? | 「有冇對藥物敏感？」 | Safety; required field | — |
| PMHx | Any past illnesses? Gallstones? DM? HBV? | 「以前有冇乜嘢病？有冇膽石、糖尿、乙型肝炎？」 | HBV → HCC; DM → gallstone risk; known gallstones → complication | HCC, complicated gallstone disease |
| FHx | Family history of gallstones or cancer? | 「屋企人有冇膽石、肝癌或者腸癌？」 | Gallstone Hx familial; liver/GI CA screening | Familial gallstone, hereditary cancer |
| Social | Occupation? Impact on work/daily life? | 「你做咩工作？呢個痛有冇影響你返工？」 | Functional impact for biopsychosocial | Social problem |
| Psych screen | How is your mood? Stress? | 「你心情點呀？最近壓力大唔大？」 | Somatisation, anxiety about diagnosis | Masquerade — anxiety |
| Menstrual/Obs (if female) | LMP? Pregnant? Contraception? | 「你月經幾時嚟？有冇可能懷孕？有冇食避孕藥？」 | Pregnancy (cholestasis); OCP (gallstone risk) | Cholestasis of pregnancy, gallstone |
Case Report Form Answer Builder
- CC: RUQ pain × [duration]
- HPI high-yield points: SOCRATES of the pain; relation to fatty meals; duration of each episode (< 6h vs > 6h); associated fever, jaundice, nausea/vomiting; colour of stool and urine; weight change; PMHx (gallstones, HBV, DM); DHx (OCP, NSAIDs); alcohol; FHx
- Examples: "Recurrent RUQ pain after meals — patient wants diagnosis and investigation" / "RUQ pain with fever — concerned about serious cause" / "Patient worried the pain may be cancer"
- Phrase it as a single sentence connecting the symptom to the patient's motivation
| Likely Example | Exact Wording | |
|---|---|---|
| Idea | "I think it might be gallstones because my mother had them" | Patient thinks pain is related to gallstones / liver problem |
| Concern | "I'm worried it could be liver cancer" | Patient is worried about cancer / serious disease |
| Expectation | "I want an ultrasound scan" / "I want pain relief" | Patient expects imaging / referral / medication |
- Biliary colic (if: episodic RUQ pain after fatty meal, < 6h, no fever, no jaundice)
- Acute cholecystitis (if: RUQ pain > 6h + fever + Murphy's sign)
- Minimum supporting evidence: pain character and duration + relation to fatty food + presence/absence of fever + Murphy's sign
High yield from GC 200: Cholecystitis — pain > 4–6h, fever, Murphy's sign positive; Biliary colic — pain < 6h, no fever, self-resolving [3]
| Domain | Problem |
|---|---|
| Biological | Recurrent biliary colic with risk of complications (cholecystitis, cholangitis, pancreatitis) |
| Psychological | Anxiety about cancer / fear of surgery / health anxiety |
| Social | Pain affecting work productivity / dietary restriction / financial concern about investigation |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Acute cholecystitis (most likely if febrile) | Murphy's sign | Place hand at RUQ at costal margin. Ask patient to breathe in deeply. Positive = patient catches breath/winces due to inflamed gallbladder descending onto examiner's fingers. Must confirm negative in LUQ (specificity). | Murphy's sign has ~97% sensitivity for acute cholecystitis [1][2] |
| Biliary colic (most likely if afebrile) | RUQ tenderness (but often normal between episodes) | Palpate RUQ — may be mildly tender during episode; no peritoneal signs, no Murphy's [2] | Absence of peritoneal signs + absence of fever distinguishes from cholecystitis |
| Acute cholangitis | Jaundice (scleral icterus) + RUQ tenderness + fever | Inspect sclera under natural light; palpate RUQ; measure temperature | Confirms Charcot's triad — pathognomonic for cholangitis [1][3] |
| Peptic ulcer disease | Epigastric tenderness (non-specific) | Palpate epigastrium | No reliable specific physical sign in FM station; best clue is history of NSAID use + meal-related pain |
| Gallstone pancreatitis | Epigastric tenderness ± guarding; pain out of proportion to signs [4] | Palpate epigastrium and periumbilical area | Pain-sign discrepancy classic for early pancreatitis |
| Right lower lobe pneumonia | Reduced breath sounds / crackles at right base | Auscultate right lung posteriorly | Referred RUQ pain from diaphragmatic irritation |
| HCC | Hard, irregular hepatomegaly ± hepatic bruit | Palpate liver from RIF upward; auscultate over liver | Hard irregular edge suggests malignancy |
Top Traps That Lose Marks
- Forgetting to ask about fever and jaundice — you cannot differentiate biliary colic / cholecystitis / cholangitis without these. Charcot's triad is a guaranteed exam point.
- Calling it "biliary colic" when pain > 6h with fever — this is cholecystitis, not colic. Duration is the key discriminator.
- Missing inferior MI — always ask about cardiac risk factors and chest tightness. Inferior MI can present as epigastric/RUQ pain with nausea.
- Not asking about HBV status — Hong Kong prevalence is high; HCC must be excluded in RUQ pain with hepatomegaly.
- Forgetting ICE — guaranteed marks; many students skip it under time pressure.
- Not examining Murphy's sign — the single most discriminating physical sign for cholecystitis in an FM station.
- Not giving a safety-net — must tell the patient red flags for urgent return (high fever, rigors, jaundice, severe worsening pain).
Must Not Miss Red Flags — Urgent Referral
- Charcot's triad / Reynold's pentad → urgent surgical referral (cholangitis/sepsis)
- Peritonism (rigid abdomen, rebound tenderness) → ?perforation, ?peritonitis → A&E
- Painless progressive jaundice + weight loss → malignancy workup (pancreatic head CA, cholangiocarcinoma)
- Signs of shock (tachycardia, hypotension) with RUQ pain → ruptured viscus / severe sepsis → A&E
- HBV carrier + new RUQ mass → urgent USG + AFP for HCC
Shortest safe management/safety-net line for closing: 「如果你痛得好犀利食止痛藥都唔好，或者發高燒、眼黃、嘔到食唔到嘢，就要即刻去急症室。」 (If pain is severe and unresponsive to analgesics, or you develop high fever, jaundice, or inability to eat/drink due to vomiting, go to A&E immediately.)
High Yield Summary
What to ASK: SOCRATES of RUQ pain; fatty meal trigger; duration < 6h vs > 6h; fever; jaundice (stool/urine colour); nausea/vomiting; weight loss; HBV status; alcohol; OCP/NSAID use; ICE.
What to WRITE: CC = "RUQ pain × duration"; Most likely Dx = biliary colic (afebrile, < 6h) or acute cholecystitis (febrile, > 6h, Murphy's +); DDx = cholangitis, gallstone pancreatitis, PUD; Biopsychosocial = gallstone complications / cancer anxiety / work impact; Physical sign = Murphy's sign.
What NOT to MISS: Charcot's triad (cholangitis); inferior MI masquerade; HCC in HBV carrier; right lower lobe pneumonia mimicking RUQ pain; DKA abdominal pain in diabetics.
Active Recall - Family Medicine Clinical Test
[1] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf — Sections on biliary colic, acute cholecystitis (p. 510, 555), acute cholangitis, Mirizzi syndrome (p. 574, 576), recurrent pyogenic cholangitis (p. 529) [2] Senior notes: Ryan Ho GI.pdf — Section 4.1.5 RUQ Pain (p. 209); Ryan Ho Fundamentals.pdf — Section 3.3.12 RUQ Pain (p. 307); Ryan Ho Cardiology.pdf — Biliary section (p. 56) [3] Lecture slides: GC 200. RUQ pain, jaundice and fever Cholecytitis and cholangitis Imaging of GI system.pdf [4] Senior notes: Block A - Upper abdominal pain_ peptic ulcer; pancreatitis and gallstone.pdf (p. 6); Maksim Surgery Notes.pdf — Diseases of biliary tract (p. 136) [5] Senior notes: Block A - Jaundice after raw oysters_ acute hepatitis.pdf (p. 2) — liver capsule distension causing dull ache [6] Senior notes: Block A - Introduction to GI_Hepatology investigations (LFT, Endoscopy).pdf (p. 10) — LFT patterns in bile duct obstruction [7] Senior notes: Maksim Medicine Notes.pdf — Section 7.1 Clinical approach, abdominal pain (p. 119) [8] Lecture slides: Clinical Demonstration_Abdomen.pdf — Surface anatomy and history taking for abdomen
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