How to take a thorough history of presenting illness in a patient with abdominal pain?

History of Presenting Illness for Abdominal Pain

When evaluating abdominal pain, begin by determining pain location, onset characteristics, and associated symptoms, as these guide diagnosis and imaging decisions more effectively than any other historical features. 1

Pain Characteristics

Location and Radiation

• Document precise pain location as this is the most useful starting point for guiding diagnosis and determining appropriate imaging 1, 2
• Right lower quadrant pain strongly suggests appendicitis 2
• Right upper quadrant pain suggests biliary disease 2
• Left lower quadrant pain suggests diverticulitis 1
• Epigastric pain suggests gastritis, peptic ulcer disease, or pancreatitis 1
• Nonlocalized or diffuse pain requires broader evaluation with CT imaging 1

Onset and Temporal Pattern

• Abrupt or instantaneous onset of severe pain is a high-risk feature that suggests vascular catastrophe, particularly aortic dissection or mesenteric ischemia 3
• Pain out of proportion to physical examination findings should be assumed to be acute mesenteric ischemia until disproven 3, 1
• Colicky pain indicates bowel obstruction as the bowel attempts to overcome occlusion 1
• Document symptom duration, as patients typically present 3-4 days after onset in Western countries, while acute presentations with peritonitis suggest already-established necrosis 1

Quality and Severity

• Ripping, tearing, stabbing, or sharp quality pain suggests aortic dissection 3
• Severe intensity pain warrants urgent evaluation 3
• The combination of abdominal pain, constipation, and vomiting suggests sigmoid volvulus, especially with previous episodes of distention 1

Associated Symptoms

Gastrointestinal Symptoms

• Ask specifically about the last bowel movement and passage of gas, which has 85% sensitivity and 78% specificity for predicting adhesive small bowel obstruction in patients with prior abdominal surgery 1, 4
• Vomiting occurs earlier and more prominently in small bowel obstruction versus large bowel obstruction 1
• Diarrhea was present in 7.7% of COVID-19 patients and may precede respiratory symptoms by several days 3
• Nausea was present in 44% of acute mesenteric ischemia patients 3
• Rectal bleeding with unexplained weight loss points toward colorectal cancer 1
• Approximately 25% of acute mesenteric ischemia patients have occult blood in stool 3

Systemic Symptoms

• Fever with abdominal pain suggests infection or abscess and requires urgent evaluation 1
• The triad of abdominal pain, fever, and hemocult-positive stools occurs in approximately one-third of acute mesenteric ischemia patients 3
• New loss of taste or smell, cough, shortness of breath, chills, muscle pain, headache, or sore throat suggest COVID-19 as a cause of GI symptoms 3

Past Medical History

Cardiovascular History

• Patients with cardiovascular disease presenting with acute abdominal pain should be suspected of having acute intestinal ischemia 3
• Atrial fibrillation is present in nearly 50% of patients with embolic acute mesenteric ischemia 3
• History of prior arterial embolus occurs in approximately one-third of embolic acute mesenteric ischemia patients 3
• Recent myocardial infarction predisposes to acute mesenteric arterial thrombosis 3
• Cardiac failure, particularly when precipitated by sepsis, predisposes to non-occlusive mesenteric ischemia 3

Surgical History

• Any prior laparotomy makes adhesive obstruction the leading diagnosis, accounting for 55-75% of small bowel obstructions 1, 4
• Recent aortic manipulation (surgical or catheter-based) predisposes to acute aortic dissection 3
• Patients who develop acute abdominal pain after arterial interventions in which catheters traverse the visceral aorta should be suspected of having acute intestinal ischemia 3
• History of chronic postprandial abdominal pain, progressive weight loss, and previous revascularization procedures suggest mesenteric arterial thrombosis 3

Other Medical Conditions

• Previous diverticulitis episodes suggest diverticular stenosis 1, 4
• Chronic constipation history raises suspicion for dolichosigmoid and volvulus 1
• Personal history of sigmoid volvulus recurs in 30-40% of cases 1
• Inflammatory bowel disease can cause stricture formation and obstruction 4

Genetic and Connective Tissue Disorders

• Patients presenting with sudden onset of severe chest, back, and/or abdominal pain, particularly those less than 40 years of age, should be questioned about and examined for Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome, or other connective tissue disorders 3
• Patients with mutations in FBN1, TGFBR1, TGFBR2, ACTA2, and MYH11 genes predispose to thoracic aortic aneurysms and dissection 3

Family History

• Family history of aortic dissection or thoracic aortic aneurysm should be documented, as there is a strong familial component to acute thoracic aortic disease 3

Medication History

• Psychotropic medications cause chronic constipation predisposing to volvulus, particularly in elderly institutionalized patients 1
• Any drugs affecting peristalsis are critical for differentiating pseudo-obstruction from mechanical obstruction 1
• Oral contraceptives and estrogen use predispose to mesenteric venous thrombosis 3
• Bevacizumab causes ulceration, fistulation, or perforation in 0.9% of patients within 1 year 4
• Tyrosine kinase inhibitors are associated with bowel perforation 4
• Use of vasoconstrictive agents may precipitate non-occlusive mesenteric ischemia 3

Social History

• Document substance use or misuse 3
• Assess impact on activities of daily living 3
• Evaluate occupational status changes related to pain 3

Special Population Considerations

Women of Childbearing Age

• Consider gynecologic conditions such as ectopic pregnancy, ovarian torsion, or pelvic inflammatory disease 1
• Beta-hCG test should be considered before imaging in all women of childbearing age with acute abdominal pain 1

Elderly Patients

• Symptoms may be atypical and require more thorough evaluation, even if laboratory tests are normal 1
• Elderly patients have higher likelihood of malignancy, diverticulitis, and vascular causes of acute abdominal pain 1
• The classic patient for sigmoid volvulus is elderly, institutionalized, and on psychotropic medications 1

Post-Bariatric Surgery Patients

• Tachycardia is the most critical warning sign in post-bariatric surgery patients, often presenting with atypical symptoms 1
• Classic peritoneal signs are often absent, and internal herniation should be considered even with normal lactate 1

Critical Red Flags Requiring Urgent Evaluation

• Severe pain out of proportion to physical findings suggests mesenteric ischemia 3, 1
• Signs of peritonitis (rigid abdomen, rebound tenderness) require urgent evaluation 1
• Hemodynamic instability suggests bleeding or sepsis 1
• Tachycardia is the most sensitive early warning sign of surgical complications and should trigger urgent investigation, even before other symptoms develop 1
• The combination of fever, tachycardia, and tachypnea predicts serious complications including anastomotic leak, perforation, or sepsis 1
• Abdominal distension with vomiting suggests bowel obstruction 1
• Syncope with abdominal pain warrants evaluation for pericardial tamponade or neurologic injury from aortic dissection 3

Common Pitfalls to Avoid

• The absence of peritonitis on examination does not exclude bowel ischemia—patients with sigmoid volvulus often lack peritoneal signs despite having established ischemia due to chronic distension masking the examination 1
• Classic peritoneal signs are often absent in post-bariatric surgery patients 1
• Normal lactate does not exclude internal herniation or early ischemia 1
• Patients with dissection-related neurologic pathology are less likely to report thoracic pain than typical aortic dissection patients 3