RLQ Pain
Right lower quadrant pain is abdominal pain localized to the area below and to the right of the umbilicus, most commonly associated with appendicitis but also with gynecologic, urologic, and bowel-related pathology.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Acute appendicitis | Periumbilical pain migrating to RLQ + anorexia + low-grade fever [1][3] | 「個痛有冇由肚臍附近轉去右下腹？有冇冇晒胃口？」 |
| Mesenteric adenitis (esp. children/young adults) | Recent URTI, RLQ pain, no peritonism [4] | 「最近有冇傷風感冒喉嚨痛？」 | |
| Serious Not To Miss | Ectopic pregnancy ♀ | Missed period + PV bleeding + haemodynamic instability | 「月經遲咗幾多日？有冇唔正常出血？有冇頭暈？」 |
| Perforated appendicitis / peritonitis | Sudden worsening → generalised rigidity, rebound, sepsis [1] | 「個痛有冇突然散晒成個肚？」 PE: guarding + rigidity | |
| Intestinal obstruction / strangulated hernia | Colicky pain + distension + vomiting + absolute constipation [5] | 「個肚有冇脹？有冇完全冇大便同放屁？」 | |
| Ovarian torsion ♀ | Sudden severe unilateral pain + nausea ± known cyst | 「個痛係唔係突然好劇烈？之前有冇發現卵巢水瘤？」 | |
| Pitfalls | Crohn's disease (ileitis) | Chronic/recurrent RLQ pain + diarrhoea + weight loss + perianal disease [6] | 「個痛係唔係成日嚟嚟去去？有冇肛門附近唔舒服？」 |
| Right-sided renal/ureteric colic | Colicky loin-to-groin pain + haematuria [2] | 「個痛有冇由腰去到大髀內側？小便有冇血？」 | |
| Pelvic inflammatory disease ♀ | Bilateral lower abdominal pain + vaginal discharge + cervical motion tenderness [1] | 「有冇白帶增多或者異味？兩邊都痛定淨係右邊？」 | |
| Right-sided cecal diverticulitis | Older patient, constant RLQ pain, clinically mimics appendicitis [3] | 「你幾多歲？以前有冇腸嘅病？」 | |
| Masquerades | DKA presenting as acute abdomen | Known DM + vomiting + abdominal pain + Kussmaul breathing [2] | 「你有冇糖尿病？有冇覺得好口渴、尿多？」 |
| Depression / somatisation | Chronic vague pain + poor sleep + low mood | 「你最近心情點？有冇瞓得差？」 | |
| Trying to Tell Me Something? | Fear of cancer; anxiety about fertility; relationship stress | Hidden agenda driving the consultation | 「你最擔心呢個痛係咩問題？」 |
High Yield from GC Lecture 195 [1]: Appendicitis is the most common surgical emergency. Classic features: periumbilical pain → RLQ migration, anorexia, low-grade fever. In women of reproductive age, ALWAYS exclude ectopic pregnancy and PID. Peritonitis signs (guarding, rigidity, rebound tenderness) indicate perforation → urgent surgical referral.
RLQ Pain — Family Medicine Clinical Test Page
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, intro, set agenda | 「你好呀，我姓X，係今日嘅醫生。請問我可以點稱呼你？今日有咩唔舒服呀？」(Hello, I'm Dr X. How should I address you? What's bothering you today?) | Friendly opening, builds rapport, names patient — interpersonal marks |
| 0:30–1:30 | Open-ended HPI → symptom analysis | 「可唔可以話我知你呢個痛係幾時開始？喺邊度痛？有冇轉位？痛嘅感覺係點？」(When did it start? Where? Does it move? What does it feel like?) | Chief complaint + HPI completeness. Capture the classic periumbilical→RLQ migration. |
| 1:30–2:30 | Red flags + associated Sx + systems review | 「有冇嘔？冇胃口？有冇發燒？大便有冇血？最後一次月經幾時？」(Vomiting? Appetite? Fever? Blood in stool? LMP?) | Screens for appendicitis complications, ectopic pregnancy, ovarian pathology — marks for targeted DDx |
| 2:30–3:30 | PMHx, Drug Hx, Allergy, FHx, Social Hx, sexual/menstrual Hx | 「你之前有冇乜嘢病？食緊乜嘢藥？有冇藥物敏感？屋企人有冇腸嘅病？你做邊行？有冇性伴侶？」 | Completeness of history domains — case report marks |
| 3:30–4:30 | ICE (Ideas, Concerns, Expectations) | 「你自己覺得係咩問題呀？(Idea) 你最擔心啲咩？(Concern) 你今日嚟睇醫生最想我幫到你啲乜嘢？(Expectation)」 | Direct marks for ICE on the Case Report Form. Uncover hidden agenda. |
| 4:30–5:15 | Signpost → summarise back | 「等我整理下你講嘅嘢：你由尋日開始肚臍附近痛，之後痛轉咗去右下腹，有啲作嘔冇胃口，有少少燒。我講得啱唔啱？」 | Summarising shows active listening — interpersonal marks |
| 5:15–6:00 | Brief exam plan, safety net, close | 「我想幫你檢查下個肚，之後可能要抽血同照超聲波。如果痛得好犀利、嘔好多、或者發高燒，要即刻返急症室。有冇嘢想問？」 | Shows safe management + safety-net advice. Closes consultation properly. |
Uncovering the hidden agenda: Always ask 「你今日點解決定嚟睇醫生？」 (Why did you decide to come today?) — the trigger may be fear of cancer, a friend who had appendicitis, or worry about fertility/pregnancy. This maps directly to the "ONE main reason for consultation" on the Case Report Form.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & migration | When did pain start? Did it move from around the belly button to the RLQ? | 「幾時開始痛？一開始喺邊度痛？有冇轉位去右下腹？」 | Classic periumbilical→RLQ migration = acute appendicitis [1] | Appendicitis |
| Character | Is it constant or colicky? Getting worse? | 「個痛係持續定係一陣一陣？有冇越嚟越痛？」 | Constant + progressive → appendicitis/diverticulitis; colicky → renal colic, IO [2] | Appendicitis vs renal colic |
| Severity | How bad 0-10? Can you walk normally? | 「痛嘅程度十分滿分幾多分？行路有冇影響？」 | Functional impact → biopsychosocial + urgency | |
| Fever | Any fever or chills? | 「有冇發燒或者打冷顫？」 | Fever + RLQ pain → appendicitis, PID, diverticulitis [1] | Appendicitis, PID, abscess |
| Anorexia / N&V | Any loss of appetite, nausea or vomiting? | 「有冇冇胃口、作嘔或者嘔？」 | Anorexia is classical for appendicitis [3] | Appendicitis |
| Bowel habit | Any diarrhoea, constipation, blood/mucus in stool? | 「大便有冇變？有冇肚瀉、便秘、有冇血或者黏液？」 | Blood/mucus → IBD, malignancy; diarrhoea → GE, Crohn's | Crohn's, colorectal CA |
| Urinary Sx | Any burning, frequency, blood in urine? | 「有冇小便痛、次數多咗、或者血尿？」 | Haematuria + colicky pain → ureteric stone; dysuria → UTI | Renal/ureteric stone, UTI |
| LMP & menstrual Hx ♀ | When was your last period? Could you be pregnant? Regular periods? | 「最後一次月經幾時嚟？有冇可能懷孕？月經準唔準？」 | Must exclude ectopic pregnancy in all women of reproductive age [1] | Ectopic pregnancy, ovarian cyst |
| Sexual Hx ♀ | Any vaginal discharge, new partner, unprotected sex? | 「有冇白帶異常、新嘅性伴侶、或者冇用安全措施？」 | Vaginal discharge + fever + bilateral lower abdominal pain → PID [1] | PID |
| Red flags | Significant weight loss? Night sweats? FHx of bowel cancer/IBD? | 「有冇體重減輕？夜晚出汗？屋企人有冇腸癌或者腸炎？」 | Screens malignancy and IBD | Colorectal CA, Crohn's |
| PMHx | Any previous surgery, similar episodes, chronic diseases? | 「以前有冇做過手術？以前有冇試過類似嘅痛？有冇長期病？」 | Previous appendicectomy rules out appendicitis; DM → atypical presentation | Adhesion IO, recurrent conditions |
| Drug Hx / Allergy | Any medications? NSAIDs? Allergies? | 「有冇食緊藥？止痛藥？有冇藥物敏感？」 | NSAIDs can mask fever; antibiotics → C. diff | Drug-related, masquerade |
| Social / Occupation | What's your job? Smoke/drink? Recent travel? | 「做邊行？有冇食煙飲酒？最近有冇去過旅行？」 | Travel → infectious cause; occupation → functional impact | Travellers' diarrhoea, GE |
| Functional impact | How has this affected your daily life/work/sleep? | 「呢個痛對你返工、瞓覺、日常生活有冇影響？」 | Captures biopsychosocial problem for Case Report | — |
Case Report Form Answer Builder
Template: "[Age] [sex] presenting with [duration] of RLQ pain, initially periumbilical, migrating to RLQ, associated with [fever / anorexia / nausea / vomiting / change in bowel habit]. No urinary symptoms / PV bleeding. LMP [date]. No significant PMHx."
Key HPI points to capture:
- Onset, duration, migration pattern
- Character (constant vs colicky), severity, progression
- Associated: fever, anorexia, N&V, bowel changes, urinary Sx
- ♀: LMP, PV bleeding/discharge, sexual history
- Red flags: weight loss, PR bleeding, peritonism features
| Scenario | Best RFC Phrasing |
|---|---|
| Acute pain, worried about appendicitis | "Acute RLQ pain for assessment and management" |
| Fear of serious disease | "RLQ pain — concerned about serious cause (e.g. cancer)" |
| Recurrent pain, seeking diagnosis | "Recurrent RLQ pain for diagnosis" |
Tip: Write it from the patient's perspective — what made them come today. Link to ICE.
| Component | Example |
|---|---|
| Idea | "I think it might be appendicitis / something wrong with my ovary" |
| Concern | "I'm worried it could be cancer / worried I might need surgery / worried about my fertility" |
| Expectation | "I want to know what it is / I want a scan / I want pain relief" |
Acute appendicitis — supported by:
- Periumbilical → RLQ pain migration
- Anorexia
- Low-grade fever
- RLQ tenderness at McBurney's point ± peritoneal signs
If female of reproductive age with missed period / PV bleeding → ectopic pregnancy takes priority until excluded.
| DDx | Key Discriminator |
|---|---|
| 1. Ectopic pregnancy ♀ | Missed period + PV bleeding + positive βhCG |
| 2. Mesenteric adenitis | Young patient + recent URTI + no peritonism [4] |
| 3. Right ureteric colic | Colicky loin→groin pain + haematuria on urinalysis |
(Adjust for clinical stem: if male, replace ectopic pregnancy with PID if female; or cecal diverticulitis / Crohn's if recurrent.)
| Domain | Problem |
|---|---|
| Biological | Acute appendicitis requiring urgent surgical assessment; risk of perforation and peritonitis if delayed |
| Psychological | Anxiety about diagnosis (e.g. fear of cancer or surgery); pain causing distress and poor sleep |
| Social/Functional | Inability to work/attend school; difficulty with ADLs due to pain; financial concern if surgery needed |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Acute appendicitis (most likely) | McBurney's point tenderness | Palpate at the point 1/3 distance from RASIS to umbilicus [3][7] | Localised peritoneal inflammation over the appendix base |
| Perforated appendicitis | Rebound tenderness / guarding / rigidity | Press deeply then release quickly — pain on release; involuntary muscle guarding [1] | Parietal peritoneal irritation from perforation → peritonitis |
| Ectopic pregnancy ♀ | Cervical motion (excitation) tenderness | On bimanual pelvic exam, gently move the cervix laterally | Peritoneal irritation from ruptured ectopic / haemoperitoneum |
| PID ♀ | Cervical motion tenderness + adnexal tenderness | Bimanual pelvic exam — pain on cervical motion and bilateral adnexal palpation [1] | Tubal/pelvic inflammation |
| Mesenteric adenitis | No reliable specific physical sign in brief FM station | RLQ tenderness present but no peritonism (no guarding/rebound); best clue: recent URTI history [4] | Diagnosis of exclusion; typically confirmed when appendix found normal at surgery or on imaging |
| Right ureteric colic | Renal angle tenderness (costophrenic angle percussion) | Percuss over the right renal angle (CVA) with the ulnar side of fist | Ureteric obstruction causing hydronephrosis and capsular stretch |
| Crohn's ileitis | RLQ mass (thickened terminal ileum/phlegmon) | Deep palpation of RLQ | Transmural inflammation with possible abscess or phlegmon |
Top Traps That Lose Marks
- Forgetting to ask LMP / pregnancy status in ALL females of reproductive age — ectopic pregnancy is the #1 must-not-miss diagnosis. Write "LMP asked" explicitly.
- Writing "abdominal pain" as chief complaint instead of "RLQ pain" — be specific.
- Omitting ICE — this is directly examined on the Case Report Form. You MUST ask all three.
- Confusing the "main reason for consultation" with the diagnosis — RFC is from the patient's perspective (e.g. "pain relief" or "worried about cancer"), NOT "appendicitis."
- Not signposting or summarising — these score interpersonal marks even if history is complete.
- Missing red flags for peritonitis/perforation — guarding, rigidity, rebound, tachycardia, fever > 38.5°C → needs urgent A&E referral, not outpatient management.
- Forgetting to ask about urinary symptoms — right ureteric colic closely mimics appendicitis.
Must-Not-Miss Red Flags → Urgent Referral
- Peritoneal signs (guarding, rigidity, rebound tenderness) → ? perforated appendicitis → urgent surgical referral
- Haemodynamic instability (tachycardia, hypotension) → ? ruptured ectopic pregnancy, massive intra-abdominal bleed → 999 / A&E
- Positive pregnancy test + RLQ pain + PV bleeding → ? ectopic pregnancy → urgent O&G referral
- High fever ( > 38.5°C) + severe toxicity → ? abscess, peritonitis → urgent surgical referral
Safety-net line for consultation close: 「如果你返到屋企個痛突然嚴重好多、發高燒、嘔到停唔到、或者覺得頭暈企唔穩，要即刻去急症室。」 (If pain worsens suddenly, high fever, uncontrollable vomiting, or dizziness → go to A&E immediately.)
High Yield Summary
What to ASK: Pain migration (periumbilical → RLQ), anorexia, fever, LMP (♀), urinary Sx, vaginal discharge (♀), red flags (peritonism, haemodynamic instability), ICE.
What to WRITE: Specific chief complaint ("RLQ pain x duration"), complete HPI with migration + associated Sx, RFC from patient's perspective, all three ICE components, acute appendicitis as most likely Dx (with McBurney's point tenderness), three DDx tailored to age/sex, biopsychosocial problems covering all three domains.
What NOT to MISS: Ectopic pregnancy in reproductive-age women, peritoneal signs suggesting perforation, ureteric colic mimicking appendicitis, and always ask ICE explicitly.
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 [2] Senior notes: Ryan Ho Fundamentals.pdf (Abdominal pain section, p.276) [3] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (Acute appendicitis, p.731-733) [4] Past papers: 2022 Fourth Summative MCQ.pdf (Q64 — mesenteric adenitis) [5] Lecture slides: GC 194. Intestinal obstruction colorectal cancer.pdf [6] Senior notes: Block A - Chronic diarrhoea_ irritable bowel syndrome and inflammatory bowel disease.pdf [7] Lecture slides: abdominal exam (MBBS IV) (student version).pdf / CFB (MED07) Examination of the Abdomen.pdf
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