What questions should be asked in the history of a patient with abdominal pain?

Essential Questions for Evaluating Patients with Abdominal Pain

A comprehensive history for patients with abdominal pain should include questions about pain characteristics, associated symptoms, medical history, and risk factors to guide diagnosis and reduce morbidity and mortality.

Pain Characteristics

• Location and radiation: Ask where the pain started and if it has moved or spread to other areas. Location helps narrow differential diagnosis (e.g., right lower quadrant pain suggests appendicitis) 1
• Onset and duration: Ask when the pain began and whether it was sudden or gradual 2
• Quality and severity: Determine if pain is sharp, dull, cramping, burning, or tearing 2, 1
• Aggravating and alleviating factors: Ask what makes the pain worse or better, including:
  • Does taking a deep breath aggravate symptoms? (suggests musculoskeletal origin) 3
  • Does twisting your back aggravate symptoms? (suggests musculoskeletal origin) 3
  • Does eating aggravate symptoms? (negative indicator for musculoskeletal origin) 3
• Temporal pattern: Ask if pain is constant, intermittent, or colicky 2

Associated Symptoms

• Gastrointestinal symptoms:
  • Last bowel movement and character of stool 2
  • Presence of gas passage 2
  • Changes in bowel habits (negative indicator for musculoskeletal origin) 3
  • Nausea and vomiting (earlier and more prominent in small bowel obstruction) 2
  • Rectal bleeding (suggestive of colorectal cancer) 2
• Systemic symptoms:
  • Fever (raises suspicion of intra-abdominal infection or abscess) 2
  • Weight changes (negative indicator for musculoskeletal origin) 3
  • Fatigue 2

Medical and Surgical History

• Previous abdominal surgeries: History of abdominal surgery has 85% sensitivity and 78% specificity for predicting adhesive small bowel obstruction 2
• Previous similar episodes: Ask about prior episodes of similar pain 2
  • Previous diverticulitis episodes (may suggest diverticular stenosis) 2
  • Chronic constipation history (may suggest volvulus) 2
• Existing medical conditions: Inquire about comorbidities that may affect surgical risk 2
• Early life adversity: Consider asking about childhood trauma, which can affect onset and expression of functional GI disorders 2

Risk Factors and Social History

• Current medications: Ask about medications that could affect peristalsis (associated with pseudo-obstruction and adynamic ileus) 2
• Impact on quality of life: Ask "How do your bowel symptoms interfere with your ability to do what you want to do in your daily life?" and "What areas of your life are affected most?" 2
• Substance use: Inquire about alcohol, tobacco, and recreational drug use 2

Special Considerations

• For suspected appendicitis: Focus on specific clinical indicators that help risk-stratify patients 2
• For elderly patients: Be aware that laboratory tests may be normal despite serious infection, and atypical presentations are common 2
• For immunocompromised patients: Consider that typical signs of abdominal sepsis may be masked 2
• For trauma patients: Ask about mechanism of injury and timing 2

Red Flags Requiring Urgent Attention

• Severe, untreatable pain (may indicate ischemia or perforation) 2
• Persistent vomiting 2
• Signs of peritonitis 2
• Unexplained weight loss (may suggest malignancy) 2, 4
• Repeated ED visits without diagnosis 5
• Disproportionate pain compared to physical examination findings 5

Remember that patients with chronic or recurrent abdominal pain may require additional assessment for functional disorders, but these should only be considered after organic pathology has been confidently excluded 4.