Abdominal pain
Exploring symptom
Pain
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating/relieving factors
Severity
Relevant system reviews
General
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
Gallstones
Biliary colic
Intermittent severe RUQ / epigastric pain
Exacerbated by fatty food (after 30-60 minutes)
Cholecystitis
Continuous RUQ / epigastric 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
Bowel obstruction
Vomiting + abdominal distension + no bowel motions
Colicky pain
Other gastrointestinal differentials
Gastroenteritis
Inflammatory bowel disease
Volvulus
Mesenteric ischaemia
Ischaemic colitis
Constipation
Urological
Renal colic
Spasms of loin to groin pain (excruciating)
Nausea and vomiting
Cannot lie still
Pyelonephritis
Gynaecological
Ectopic pregnancy
Increasing iliac fossa / pelvic pain
4-12 weeks gestation / not using contraception / recent period of amenorrhoea
May have spotting
Pelvic inflammatory disease
PV discharge
Lower abdominal pain
Dyspareunia
Risk factors (e.g. new or multiple sexual partners)
Endometriosis
Lower abdominal pain, worst during menstruation
Dyspareunia
Others
Ruptured AAA
MI
Pneumonia
DKA
Change in bowel habit
Exploring symptom
Timeframe
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 + anaemia 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
Other gastrointestinal differentials
Bowel obstruction (not passing flatus)
Perianal conditions (haemorrhoids, fissure)
Overflow constipation
Lactose intolerance
Malabsorption (pancreatic insufficiency, bile acid malabsorption)
Diverticulitis
Endocrinological
Thyrotoxicosis
Diarrhoea
Heat intolerance
Irritability/restlessness
Tremor
Oligomenorrhoea/amenorrhoea
Hypothyroidism
Constipation
Cold intolerance
Lethargy/tiredness
Menorrhagia
Others
Diet and lifestyle changes
Drugs (e.g. opiates, iron, antacids, antibiotics)
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
Upper GI (melaena)
Oesophageal varices
History of liver disease/alcoholism
May have encephalopathy or alcohol withdrawal
Haematemesis
Haemorrhagic peptic ulcer/ gastritis
Gastritis symptoms
Haematemesis
Risk factors, e.g. NSAIDs, alcohol, spicy food
Lower GI (fresh red PR bleeding)
Proximal polyp/malignancy
Weight loss
Anaemia symptoms
Proximal polyp/malignancy
Weight loss
Anaemia symptoms
Angiodysplasia
Elderly
Painless
May be subtle
Haemorrhagic infective gastroenteritis
Acute diarrhoea and vomiting
History of high risk food intake
Inflammatory bowel disease
Blood mixed with stool
Mucus
Diarrhoea
Abdominal pain
Weight loss
Distal polyp/malignancy
Alternating bowel habit
Weight loss
Urgency/tenesmus
Anal discomfort/pruritus
Diverticular haemorrhage
Sudden painless rectal bleeding
Elderly
Haemorrhoids
Bleeding on defecation
Bright red on tissue paper
Constipation history
Anal pruritus
Anal fissure
Bleeding on defecation
Bright red on tissue paper
Intense anal pain
Constipation history
A patient presents to ED with chest pain and this trace. What would you do?
Interpretation management
Covered in OSCE Stations
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
Gatrointestinal
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?
Change in bowel habit Diarrhoea Abdominal pain Diverticulitis And there’s so much more!
