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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

  • 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
    • Charcotโ€™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

  • 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 intoleranceย 
  • 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 โ€“ 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)

  • 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 historyย 
  • 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 haematemesisย 
  • 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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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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