Table of Contents Abdominal pain GastrointestinalUrologicalGynaecologicalOthersChange in bowel habit GastrointestinalEndocrinologicalOthersRectal bleeding Upper GI (melaena) Lower GI (fresh red PR bleeding)HaematemesisGastrointestinalTry some questionsWant to test yourself? 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 GallstonesAcute pancreatitisGastritis/peptic ulcerDiverticulitisBowel obstructionOther 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 Renal colic Pyelonephritis Spasms of loin to groin pain (excruciating) Nausea and vomiting Cannot lie still Loin pain Fever Dysuria Gynaecological Ectopic pregnancy Pelvic inflammatory diseaseEndometriosis 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 cancerGastroenteritisInflammatory bowel diseaseIrritable bowel syndromeCoeliac diseaseOther 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 Thyrotoxicosis Hypothyroidism 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) Oesophageal varicesHaemorrhagic peptic ulcer/ gastritis 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/malignancyAngiodysplasiaHaemorrhagic infective gastroenteritisInflammatory bowel diseaseDistal polyp/malignancyDiverticular haemorrhageHaemorrhoids 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 Oesophageal varicesMallory-Weiss tearPeptic ulcer haemorrhage/ haemorrhagic gastritis/ oesophagitis 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? Oops! This section is restricted to members. 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? Oops! This section is restricted to members. Want to test yourself? Change in bowel habit Diarrhoea Abdominal pain Diverticulitis And there’s so much more!