History of Present Illness (HPI) Template for Male Patient with Abdominal Pain in ER
A comprehensive HPI template for abdominal pain should include all key elements of pain assessment, associated symptoms, and risk factors to guide diagnosis and management. 1
Pain Characteristics Template
Mr. _____ is a _____ year-old male who presents to the Emergency Department with a chief complaint of abdominal pain that began _____ (hours/days) ago. The pain is located primarily in the _____ quadrant(s) of the abdomen and is described as _____ (sharp/dull/burning/cramping/colicky) in nature. The pain is rated as _____ out of 10 in severity. The pain _____ (radiates/does not radiate) to _____ (back/groin/chest/shoulder). The onset was _____ (sudden/gradual) and the course has been _____ (constant/intermittent/worsening/improving). The pain is _____ (aggravated by/relieved by) _____ (movement/eating/position changes/medication).
Associated Symptoms
Patient _____ (reports/denies) associated symptoms including:
- Fever: _____ (temperature if known)
- Nausea: _____ (yes/no)
- Vomiting: _____ (yes/no, frequency, character)
- Change in bowel habits: _____ (constipation/diarrhea/normal)
- Last bowel movement: _____ (time, character)
- Blood in stool: _____ (yes/no)
- Urinary symptoms: _____ (dysuria/frequency/urgency/hematuria)
- Appetite changes: _____ (decreased/normal)
Alarm Symptoms and Risk Assessment
Patient _____ (reports/denies) alarm symptoms including:
- Tachycardia (heart rate ≥ 110 beats per minute): _____ (yes/no)
- Respiratory distress or tachypnea: _____ (yes/no)
- Decreased urine output: _____ (yes/no)
- Hematemesis: _____ (yes/no)
- Melena or hematochezia: _____ (yes/no)
- Persistent vomiting: _____ (yes/no)
Past Medical History Elements
Patient _____ (has/does not have) relevant past medical history including:
- Previous abdominal surgeries: _____ (type and date)
- History of bariatric surgery: _____ (type and date) 1
- Cardiovascular disease: _____ (especially atrial fibrillation) 1
- History of prior arterial emboli: _____ (yes/no)
- Inflammatory bowel disease: _____ (yes/no)
- Diverticulitis: _____ (yes/no)
- Gallbladder disease: _____ (yes/no)
- Pancreatitis: _____ (yes/no)
- Kidney stones: _____ (yes/no)
Medication and Social History
Patient is currently taking _____ medications. Specifically, _____ (anticoagulants/NSAIDs/steroids/opioids/other relevant medications).
Patient _____ (reports/denies) alcohol use of _____ drinks per day/week. Patient _____ (is a current/former/never) smoker with _____ pack-year history. Patient _____ (reports/denies) illicit drug use.
Prior Evaluation and Treatment
Patient _____ (has/has not) sought medical attention for this complaint previously. Prior workup included _____ (labs/imaging/procedures) with results showing _____. Patient _____ (has/has not) tried _____ (medications/home remedies) with _____ (improvement/worsening/no change) in symptoms.
Clinical Impression
Based on the patient's presentation with _____ (key symptoms), located in the _____ (location) with associated _____ (key associated symptoms), the differential diagnosis includes _____ (top 3 diagnoses). The most concerning diagnosis to rule out is _____ based on _____ (key clinical features). 1, 2
Note: This template is designed to capture all essential elements of the HPI for a male patient presenting with abdominal pain. The comprehensive approach ensures that key diagnostic clues for serious conditions such as mesenteric ischemia, appendicitis, diverticulitis, and bowel obstruction are not missed. 1, 2