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Common abdominal histories

Abdominal pain

Exploring symptom

  • Pain
    • Site
    • Onset
    • Character
    • Radiation
    • Associated symptoms
    • Timing
    • Exacerbating/relieving factors
    • Severity

Relevant system reviews

  • General
    • Fever, sweats
  • Gastrointestinal
    • Weight: loss, appetite change
    • Work down body: dysphagia, nausea/vomiting, indigestion/heartburn, bowel habit change, tenesmus, blood/mucus in stool
  • Urological
    • Storage: frequency, volume, urgency, nocturia, incontinence
    • Infection: dysuria, haematuria, odour
  • Gynaecological
    • PV bleeding: menorrhagia, intermenstrual, post-coital, post-menopausal 
    • PV discharge
    • Pain: pelvic, dysmenorrhoea, dyspareunia
    • Pregnancy risk

Differential diagnoses and clues

Gastrointestinal:

Appendicitis-Most commonly young patient
-Periumbilical pain
-Moves to RIF
-Anorexia
GallstonesBiliary colic
-Intermittent severe RUQ / epigastric pain
-Exacerbated by fatty food (after 30-60 minutes) 

Cholecystitis
-Continuous RUQ / epigastric pain 

CBD stones
-Jaundice
-RUQ pain 

Cholangitis 
– Charcot’s triad = Jaundice, Fever/rigors, RUQ pain
Acute pancreatitis-Severe epigastric / central pain
-Radiating to back
-Relieved by sitting forwards
-Vomiting
Gastritis/peptic ulcer-Epigastric pain related to meals
-Risk factors, e.g. NSAIDs, alcohol, spicy food
Diverticulitis-Elderly
-LIF pain
-Pyrexia
Bowel obstruction-Vomiting + abdominal distension + no bowel motions
-Colicky pain

Urological:

Renal colic-Spasms of loin to groin pain (excruciating)
-Nausea and vomiting
-Cannot lie still

Gynaecological:

Ectopic pregnancy-Increasing iliac fossa / pelvic pain
-4-12 weeks gestation / not using contraception / recent period of amenorrhoea
-May have spotting

Others:

Other differentialsRuptured AAA, Gastroenteritis, Volvulus, Pyelonephritis, IBD, Mesenteric ischaemia/ischaemic colitis, Pelvic inflammatory disease, Endometriosis, Constipation, Non-abdominal (MI, pneumonia, DKA)

Change in bowel habit

Exploring symptom

  • Timeframe
    • Duration
    • Progression
  • Stool
    • How much, how often
    • Consistency, colour and contents (mucus, blood)

Relevant system reviews

  • Gastrointestinal
    • Weight: loss, appetite change
    • Work down body: dysphagia, nausea/vomiting, indigestion/heartburn, abdominal pain, tenesmus, blood/mucus in stool, flatus

Differential diagnoses and clues

Gastrointestinal:

Colon cancer -Elderly
-Blood in stool / melaena
-Weight loss + an
aemia Sx (SOB, tiredness)
Gastroenteritis-Acute diarrhoea
-Nausea and vomiting
Inflammatory bowel disease-Blood/mucus in stool
-Abdominal pain          
-Weight loss
Irritable bowel syndrome-Fluctuate between diarrhoea/constipation
-Anxious personality/associated with stress
-Crampy abdominal pain and bloating
Coeliac disease-Diarrhoea, steatorrhoea
-Anaemia symptoms
-Abdominal discomfort

Endocrinological:

Thyrotoxicosis  -Diarrhoea
-Heat intolerance
-Irritability/restlessness
-Tremor
-Oligomenorrhoea/amenorrhoea
Hypothyroidism-Constipation
-Cold intolerance 
-Lethargy/tiredness
-Menorrhagia

Others:

Other differentialsBowel obstruction (not passing flatus), Diet and lifestyle changes, Perianal conditions (haemorrhoids, fissure), Drugs (e.g. opiates, iron, antacids, antibiotics), Diverticulitis, Overflow constipation, Lactose intolerance, Malabsorption (pancreatic insufficiency, bile acid malabsorption)

Rectal bleeding

Exploring symptom

  • Timeframe
    • Duration
    • Onset (sudden or gradual)
    • Progression – how often?
    • Timing (intermittent or continuous)
  • Rectal bleeding
    • Blood: fresh/altered/ melaena
    • On tissue or mixed in stool
    • When does it occur
  • Stool
    • Any mucus
    • How much, how often, consistency

Relevant system reviews

  • Gastrointestinal
    • Weight: loss, appetite change
    • Work down body: dysphagia, nausea/vomiting, indigestion/heartburn, abdominal pain, bowel habit change, mucus in stool

Differential diagnoses and clues

Gastrointestinal:

Anal fissure -Bleeding on defecation
-Bright red on tissue paper
-Intense anal pain
-Constipation history 
Haemorrhoids -Bleeding on defecation
-Bright red on tissue paper
-Constipation history 
-Anal pruritus
Diverticular haemorrhage -Sudden painless rectal bleeding
-Elderly
Distal polyp/ malignancy-Alternating bowel habit
-Weight loss
-Urgency/tenesmus
-Anal discomfort/pruritus
Inflammatory bowel disease-Blood mixed with stool
-Mucus
-Diarrhoea
-Abdominal pain
-Weight loss
Haemorrhagic infective gastroenteritis-Acute diarrhoea and vomiting
-History of high risk food intake
Angiodysplasia-Elderly
-Painless
-May be subtle
Proximal polyp/ malignancy-Weight loss
-Anaemia symptoms
Haemorrhagic peptic ulcer/ gastritis-Gastritis symptoms
-Haematemesis
-Risk factors, e.g. NSAIDs, alcohol, spicy food
Oesophageal varices-History of liver disease/alcoholism
-May have encephalopathy or alcohol withdrawal
-Haematemesis

Haematemesis

Exploring symptom

  • Timeframe
    • Duration
    • Progression
    • Timing (intermittent or continuous)
  • Vomit
    • How much, how often, 
    • Consistency, colour and contents (blood)

Relevant system reviews

  • Gastrointestinal
    • Weight: loss, appetite change
    • Work down body: dysphagia, indigestion/heartburn, abdominal pain, bowel habit change, blood in stool/melaena

Differential diagnoses and clues

Gastrointestinal:

Oesophageal varices-History of liver disease/alcoholism
-May have encephalopathy or alcohol withdrawal
Mallory-Weiss tear-Multiple vomits before haematemesis 
-Commonly after binge drinking
Peptic ulcer haemorrhage /haemorrhagic gastritis/ oesophagitis-Previous gastritis symptoms
-Risk factors, e.g. NSAIDs, alcohol, spicy food

Try some questions

A patient presents to the emergency department after vomiting blood. What would you want to know about their past medical/drug/social history?

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A 19 year old female presents with a constant central abdominal pain for 12 hours, which his now moved to the right iliac fossa. Which systems review questions would you ask? Which conditions would you think about for each symptom group?

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Want to test yourself?

  1. Change in bowel habit
  2. Diarrhoea
  3. Abdominal pain
  4. Diverticulitis
  5. And there’s so much more!
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