Medically Fit For Exams
Medically Fit For Exams

Abdominal pain history taking


Differential diagnoses

Pancreatitis (acute or chronic)




Peptic ulcer

Kidney calculi




Colorectal cancer

Urinary retention


Ectopic pregnanc

  • Wash hands and introduce yourself to the patient
  • Check patient’s name and DOB
  • Ask is it’s okay to talk to the patient before they see the doctor


History of presenting complaint

  • Ask the patient what has brought them in today
  • Ask them to tell you more about their pain
  • Clarify the pain using the SOCRATES mnemonic
    • Site
      • Epigastric (pancreatitis, gallbladder)
      • Right hypogastric (cholecystitis, cholangitis)
      • Umbilical (appendicitis, IBD, IBS, constipation)
      • Suprapubic (IBD, IBS, urinary retention, UTI, constipation, menstrual pain)
      • Flank/Loin (Kidney calculi)
  • Onset
    • Sudden
    • Insidious
    • Over how long?
  • Character
    • Colicky/squeezing/cramping (constipation, gallstones)
    • Dull
    • Sharp
  • Radiation
    • Epigastric to back (pancreas)
    • Epigastric to right shoulder (gallbladder)
    • Loin to groin (kidney calculi)
    • Umbilical to right iliac fossa (appendicitis)
  • Associated symptoms
    • Nausea
    • Diarrhoea
    • Steatorrhoea (biliary obstruction)
    • Fever (pancreatitis, cholecystitis, )
  • Time course
    • Constant?
    • Progressively worse (appendicitis)
    • Related to menstruation (endometriosis)
  • Exacerbating/relieving factors
    • Worse when hungry (?stomach ulcer)
    • Worse when just eaten (gallbladder, ?duodenal ulcer)
  • Severity
    • Intense (acute pancreatitis, appendicitis, cholelithiasis)
  • Change in bowel habits

Cholelithiasis (stones)

Colic pain in right upper quadrant/epigastrium

Radiation to right shoulder tip (Collin’s sign)

Pain 1 hour ish after eating



Pain not relieved by painkillers or antacids

No fever or tachycardia or jaundice

Cholecystitis (inflammation of gallbladder, 99% caused by stones)

Colic pain in right upper quadrant/epigastrium

Radiation to right shoulder tip (Collin’s sign)

Possible guarding

Gallbladder palpable in 30%

Fever, jaundice unlikely

Cholangitis (infection of gallbladder)

Colic pain in right upper quadrant/epigastrium

Radiation to right shoulder tip (Collin’s sign)

Possible guarding

Classic triad = RUQ pain, fever, jaundice

Fever and jaundice likely

  • Frequency
  • Consistency
  • Blood/mucus
  • Cancer screen
    • Weight loss
    • Swallowing difficulties
    • Melena
    • Vomiting blood/haematemesis
    • Reflux/heartburn
    • Blood in the urine
    • Pain on intercourse (dyspareunia) (cervical cancer)
    • Bloating, irregular periods, bleeding/pain on intercourse, back pain, constipation, polyuria (ovarian cancer)
  • Pregnancy screen
    • Ask if there is any chance the patient could be pregnant
    • Ask when their last period was
    • PV (per vagina) bleeding: think ectopic pregnancy
  • Summarise
  • ICE
    • Ask if there is anything in particular that the patient is concerned about
    • Ask if there is anything they think is causing their problem
  • Systems enquiry if relevant
    • Weight loss and appetite change
    • Tiredness
    • Headache, faints, fits
    • Change in vision or sensation
    • Cough
    • Breathlessness
    • Chest pain
    • Aches and pains

Risk factors for gallstones





Family history









Past medical history

  • Ask if they have any current or past medical problems
  • Ask about previous surgery
  • Ask about stomach ulcers, reflux, heart disease (ACS can present as abdo pain), pancreatitis
  • Recent endoscopy (if suspect pancreatitis)


Family history

  • Ask about history of tummy problems in the family
    • Ulcers
    • IBD
  • Ask about any serious illness in the close family


Drug history

  • Ask if they take any medication
    • NSAIDs (stomach ulcer)
      • Ask about PPI or other protection
    • Steroids (acute pancreatitis)
    • Oestrogens, azathioprine, tetracylines, sulphonamides (acute pancreatitis)
  • Ask about over the counter medication
    • Aspirin
    • Ibuprofen



  • Ask if the patient has any allergies
  • Ask what happens


Social history

  • Ask about smoking (IBD, bladder cancer, stomach cancer, pancreatitis)
  • Ask about drinking (stomach ulcer, stomach cancer)
  • Ask about occupation



  • Ask if the patient has any questions or anything they are concerned about
  • Ask the patient if they think you have missed anything
  • Thank the patient for talking to you


Next steps

In all cases

Abdominal examination, pregnancy test if female

If suspect acute pancreatitis

Admit to hospital, antibiotics, amylase, glucose, lipase, CT imaging

Chronic pancreatitis

Amylase, glucose, lipase, CT imaging, CRP/ESR, FBC

Gallbladder pathology

Ultrasound, ERCP, MRCP, FBC, LFTs


Admit, CRP, CT imaging, FBC, ultrasound, microbiology of appendix

Peptic ulcer

Endoscopy, H. pylori testing


PR, CRP/ESR, p-ANCA, p-ASCA, colonoscopy, CT/MRI


?PR, FBC, CRP, LFTs, TFTs, U&Es, diet modification eg FODMAP, advise on hydration and fibre, medication eg movicol, immodium



Cancer referrals for abdominal pain

>40, abdo pain + weight loss

2 week wait referral, colorectal

<50, abdo pain + rectal bleeding

2 week wait referral, colorectal

>55, upper abdo pain + weight loss

2 week wait gastroscopy, oesophageal or stomach

>55, upper abdo pain + anaemia OR raised platelets OR nausea and vomiting

Non-urgent gastroscopy, oesophageal or stomach

>60, abdo pain + weight loss

2 week wait CT, pancreas






Epigastric pain, radiating to back, worsening pain, nausea, vomiting.

Severe cases: oliguria, tachycardia, hypotension.

In necrotising pancreatitis: Cullen’s sign (umbilical bruising) and Grey Turner’s sign (flank bruising)

Gallbladder pain

Epigastric or RUQ pain, radiating to shoulder tip, cramping/colic pain, worse after eating, nausea/vomiting, steatorrhoea, belching, fever/tachycardia in cholecystitis, fever/tachycardia + jaundice in cholangitis


Umbilical pain, spreading to right iliac fossa, fever, nausea, vomiting, anorexia, rebound pain in RLQ

Peptic ulcer

Epigastric pain.

Stomach: pain straight after eating, anorexia, weight loss.

Duodenal: pain relieved by eating/milk, or pain 2-3 hours after eating, relieved by antacids, relieved by rest


Retrosternal chest pain, worse when lying down and after eating, relieved by antacids


Generalised or variable abdominal pain, exacerbated by stress, may be exacerbated by certain types of foods (variable between people), periods of diarrhoea


Diarrhoea (bloody), RLQ pain (Crohn’s may mimic appendicitis), bloating, weight loss, anal/perianal lesions, clubbing, anaemia, palpable mass (ulcer), fatigue.

Colitis: tenesmus, urgency, proctitis


Abdominal pain, reduced stool passing, change in stool consistency, straining, nausea/vomiting, overflow diarrhoea

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