Table of Contents
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
- Gallstones
- Acute pancreatitis
- Gastritis/peptic ulcer
- Diverticulitis
- Bowel obstruction
- Other gastrointestinal differentials
- Most commonly young patient
- Periumbilical pain
- Moves to RIF
- Anorexia
- Biliary 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
- Severe epigastric / central pain
- Radiating to back
- Relieved by sitting forwards
- Vomiting
- Epigastric pain related to meals
- Risk factors, e.g. NSAIDs, alcohol, spicy food
- Elderly
- LIF pain
- Pyrexia
- Vomiting + abdominal distension + no bowel motions
- Colicky pain
- Gastroenteritis
- Inflammatory bowel disease
- Volvulus
- Mesenteric ischaemia
- Ischaemic colitis
- Constipation
Urological
- Spasms of loin to groin pain (excruciating)
- Nausea and vomiting
- Cannot lie still
- Loin pain
- Fever
- Dysuria
Gynaecological
- Increasing iliac fossa / pelvic pain
- 4-12 weeks gestation / not using contraception / recent period of amenorrhoea
- May have spotting
- PV discharge
- Lower abdominal pain
- Dyspareunia
- Risk factors (e.g. new or multiple sexual partners)
- Lower abdominal pain, worst during menstruation
- Dyspareunia
Others
- Ruptured AAA
- 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
- Gastroenteritis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Coeliac disease
- Other gastrointestinal differentials
- Elderly
- Blood in stool / melaena
- Weight loss + anaemia Sx (SOB, tiredness)
- Acute diarrhoea
- Nausea and vomiting
- Blood/mucus in stool
- Abdominal pain
- Weight loss
- Fluctuate between diarrhoea/constipation
- Anxious personality/associated with stress
- Crampy abdominal pain and bloating
- Diarrhoea, steatorrhoea
- Anaemia symptoms
- Abdominal discomfort
- Bowel obstruction (not passing flatus)
- Perianal conditions (haemorrhoids, fissure)
- Overflow constipation
- Lactose intolerance
- Malabsorption (pancreatic insufficiency, bile acid malabsorption)
- Diverticulitis
Endocrinological
- Diarrhoea
- Heat intolerance
- Irritability/restlessness
- Tremor
- Oligomenorrhoea/amenorrhoea
- 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)
- History of liver disease/alcoholism
- May have encephalopathy or alcohol withdrawal
- Haematemesis
- Gastritis symptoms
- Haematemesis
- Risk factors, e.g. NSAIDs, alcohol, spicy food
Lower GI (fresh red PR bleeding)
- Proximal polyp/malignancy
- Angiodysplasia
- Haemorrhagic infective gastroenteritis
- Inflammatory bowel disease
- Distal polyp/malignancy
- Diverticular haemorrhage
- Haemorrhoids
- Anal fissure
- Weight loss
- Anaemia symptoms
- Elderly
- Painless
- May be subtle
- Acute diarrhoea and vomiting
- History of high risk food intake
- Blood mixed with stool
- Mucus
- Diarrhoea
- Abdominal pain
- Weight loss
- Alternating bowel habit
- Weight loss
- Urgency/tenesmus
- Anal discomfort/pruritus
- Sudden painless rectal bleeding
- Elderly
- Bleeding on defecation
- Bright red on tissue paper
- Constipation history
- Anal pruritus
- Bleeding on defecation
- Bright red on tissue paper
- Intense anal pain
- Constipation history
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
- History of liver disease/alcoholism
- May have encephalopathy or alcohol withdrawal
- Multiple vomits before haematemesis
- Commonly after binge drinking
- 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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