Abdomen: History

Abdomen: History

Chief Complaints

·         Pain abdomen

·         Vomiting

·         Sensation of fullness after meals

·         Vomiting of blood

·         Passage of black tarry stool

·         Yellowish discoloration of eyes and urine

·         Loss of appetite

·         Weight loss

·         Alteration of bowel habit

·         Swelling/Lump in abdomen

History of Present Illness

1.       Pain

−        Onset: Sudden/insidious

−        Duration: Short-lived/persistent

−        Initial site of pain

−        Radiation/Shifting/Referral

−        Character of pain: Dull-aching (chronic cholecystitis)/ stabbing (pancreatitis)/colicky(Intestinal colic)

−        Periodicity of pain (Duodenal ulcer recur periodically)

−        Relation with food intake

§  Before – Duodenal ulcer

§  After- Gastric ulcer

−        Aggravating and relieving factors: Food/vomiting/medicines

2.       Vomiting

−        Duration

−        Frequency: No of episodes/day  

−        Relationship with food intake

−        Projectile or effortless

−        Character of the vomitus

−        Amount/Color

−        Taste/Smell

−        Contains any food taken more than 12 hours earlier

−        Any blood in vomiting (upper gastrointestinal bleeding)

−        relation with pain

3.       Blood in vomitus (Hematemesis)

−        Duration

−        Number of bouts of blood vomiting

−        Color

−        Amount

−        Association with black tarry stool or not

4.       Jaundice

−        Duration

−        Onset

−        Prodromal symptom before onset: Fever/arthralgia/generalized weakness/loss of appetite/skin rash (viral-hepatitis)

−        Any history of biliary colic preceding the onset of jaundice

−        Progress of jaundice

§  Progressively increasing

§  Diminishing after an initial deepening

§  Waxing and waning

§  Static

-          Associated symptoms with jaundice:

§  Pruritis: obstructive jaundice

§  Clay colored stool: Obstructive jaundice

-          History of fever with chill and rigor—cholangitis

-          History of biliary colic

-          History of black tarry stool with waxing and waning of jaundice

5.       Bowel habit

·         usual bowel habit before the illness

·         present bowel habit

·         change in bowel habit

·         Any bleeding P/R or black tarry stool, passage of mucus in stool

·         Any sensation of incomplete defecation

·         Any history of tenesmus

6.       Swelling/Lump in the abdomen

·         Duration

·         Site at onset

·         Size of the swelling when first noticed

·         Progress of the swelling

7.       Details of urinary symptoms

·         Loin pain

·         Frequency of micturition (diurnal and nocturnal)/difficulty in passing urine/any burning during micturition

·         Any urgency or hesitancy

·         Any history of passage of blood or pus in urine