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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

    • Periumbilical pain moving to RIF

Gallstones

  • 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

Acute pancreatitis

    • Severe constant epigastric pain

    • Radiating to back

    • Nausea and 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 severe loin to groin pain
    • Dysuria/haematuria

    • Nausea and vomiting

    • Restlessness

Pyelonephritis

  • Loin pain
  • Fever
  • Dysuria

Gynaecological

Ectopic pregnancy

  • Increasing iliac fossa / pelvic pain
  • 4-12Β 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

Others

  • Ruptured AAA
  • Gastroenteritis
  • Volvulus
  • Pyelonephritis
  • IBD
  • Mesenteric ischaemia/ischaemic colitis
  • Pelvic inflammatory disease
  • Endometriosis
  • Constipation
  • Non-abdominal (e.g. 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 + 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

Endocrinological

Thyrotoxicosis

  • Diarrhoea
  • Heat intolerance
  • Irritability/restlessness
  • Tremor
  • Oligomenorrhoea/amenorrhoea

Hypothyroidism

  • Constipation
  • Cold intolerance
  • Lethargy/tiredness
  • Menorrhagia

Others

Others

  • Small bowel obstruction (not passing flatus)
  • Changes in oral intake (food/fluid)
  • Medication side effects
  • Overflow diarrhoea due to constipation
  • Dietary intolerances (e.g. lactulose)
  • Malabsorption (e.g. 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

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

HaemorrhoidsΒ 

  • 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

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?

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

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