©DR.

ELVIS
 History Taking for Abdomen
1. Patient details
2. Chief complain
3. History of presenting illness (HOPI)
4. Menstrual History
5. Personal History
6. Past history
7. Family history
8. Social history

©DR. ELVIS
 1. Patient details
• Name –

• Age –

• Gender -

• Hailing from (Address )_____

• Educated up to ___

• Working as a (Occupation)- ______

• Socio-economic status –
©DR. ELVIS
2. Chief complain (with duration & Chronological order)
A. Abdomen pain

B. Abdomen distension

C. Vomiting

D. Fever

E. Hematemesis

F. Yellow discoloration of eyes & high color urine (Jaundice)

G. Diarrhea/constipation

H. Anorexia , dyspepsia , indigestion

©DR. ELVIS
3. History of presenting illness (HOPI)
• Patient was apparently well ___ months back , when
she/he noticed - e.g -abdomen distension or had an
episode of vomiting ,etc.

• Elaborate symptoms – duration , chronological order

• Etiology/ cause/ risk factors –

• Complications -

• h/o DM/HTN -

©DR. ELVIS
a) History of Pain (SOCRATES)
• Site – localized/ diffuse/ generalized

• Onset– sudden/ Rapid / Gradual

• Character – sharp/constant dull /burning

sensation/colicky

• Radiation –

• Associated symptoms – vomiting , loose motions

• Timing / Duration, course – episodic/continuous ,

duration

• Exacerbating & Relieving factors – specific posture , drugs

• Severity/ Intensity - ©DR. ELVIS

b) History in Abdomen distension
• Onset – insidious / sudden / gradual

• Progression -

• Associated with leg swelling/ facial puffiness?

• Aching pain all over the abdomen ?

• History of Ascitic tap ?

• Dyspepsia , heart burn , dyspnea ?

©DR. ELVIS
* Common causes of Abdomen distension (F’s)
• Fat - Obesity

• Fatus – Obstruction, gastric perforation

• Faeces – Constipation, gut obstruction, megacolon

• Fluid – Ascites, tumour

• Fetus -- Pregnancy

• Fibroid

©DR. ELVIS
 c) History of Dysphagia
• Onset – gradual/abrupt

• Duration –

• Progression – chronic / progressive / intermittent

• More for solids or liquids or both ?

Liquid- Neurological (eg. Stroke)
Solid – Neuromuscular (Achalasia, pharyngeal pouch, Myasthenia gravis)

• Any feeling of food sticking or fullness of esophagus or associated with

heart burn ?
©DR. ELVIS
 d) History in Dyspepsia / Indigestion
Does the patient have heartburn but call it indigestion? Is it Heart burn ?
(substernal burning sensation) - *GERD

• Is there postprandial nausea? *

• If vomiting has occurred, - nature? volume? acidic? bilious? undigested food?

• Does the patient have upper abdominal bloating, fullness, or discomfort?–

Aerophagia, delayed gastric emptying

• Are belching and flatulence prominent?

• Drugs - NSAIDs
©DR. ELVIS
 E) History in vomiting
• Associated/ Preceeded with nausea (sensation of feeling sick) – (migraine)

• Frequency / no. of episode – (electrolyte imbalance, dehydration)

• Projectile / Non Projectile type ----- (intracranial pressure)

• Content & quantity – *relation to meals

• Blood stained or Bile stained ?

• Associated with tinnitus, headache , Diarrhea , fever ?

• H/o of any emetic drugs

©DR. ELVIS
 *D/D of Vomitting

• Medical: Acute viral hepatitis, Intestinal infection, raised ICP,

DKA, MI, Migraine,

• Surgical: Acute pancreatitis, cholecystitis, intestinal obstruction

• MISC: Drug induced (digoxin), chronic alcoholism, pregnancy

©DR. ELVIS
 F ) History in Hematemesis
*Differentiate from Hemoptysis (tingling, frothy blood,alkaline)

• No. of episodes –

• mixed with food ?

• Fresh blood / altered (*coffee ground) (Hemoglobin + acid = acid hematin)

• Amount of blood –

• Associated with Malena ?

• Ingestion of any drugs - NSAIDs?

©DR. ELVIS
*Pseudohaematemesis –
 G) History in Jaundice (*suggestive of Jaundice)
• Onset – days to weeks / weeks / intermittent

• No. of episode –

• Duration –

• Color of urine & stool –

• Associated with Pruritus or Pain, GI disturbance?

• With any rash & sore throat ?

• Relation with fever ? *Jaundice after a fever---- viral hepatitis

• h/o any drug intake - *Rifampicin , ©DR. ELVIS

Quinine
 H ) History in Fever

• onset –

• Duration & progression –

• Associated with chills & rigor ? (Malaria, UTI, cholangitis, lung abscess)

• Evening Rise of temperature ? (eg TB)

• Associated with vomiting , abdomen pain, loose motion ?

• Fever with jaundice – Malaria, Typhus hepatitis

©DR. ELVIS
 I ) History of a Mass per Abdomen

• Onset – sudden/insidious

• Duration –

• Site -

• Size & growth rate – *rapid growth in malignant lesion

• Associated with pain, weight loss ?

©DR. ELVIS
 J ) History of Stools
• Amount –

• Solid / watery ?

• Colour – clay colored /brown colour / black (*Malena, iron tab., bismuth,
charcoal)

• Passing of flatus -

• Blood / mucous stained ?

• Worms in stool ?

• Tenesmus – Bacillary dysentery, IBD,

©DR.impacted
ELVIS faeces
 K ) History in Constipation
*hypothyroidism, lack of dietary fibre, fecal impaction, intestinal obstruction

• How often patient used to have bowel movements before as compared to

now ?(Bowel habits) -- (Normal is 3bowels/day to 1bowel/3days).

• Quantity , consistency –

• Is it painful to pass stool

• Do patient feel that there is stool remaining in your rectum?

• H/o drug intake - anticholinergic properties , opioids

©DR. ELVIS
 L ) History in Diarrhea (acute vs. chronic)
• Frequency of stool

• Volume & quantity of stool

• Time of Occurrence – night or day

• Nature, colour & consistency of stool -

• Aggravating & reliving factors – food, drugs

• presence of blood/ Mucous

• Drug (*quinidine, colchicine, clindamycin)/ Travel / Recent Food history -

• Associated with abdomen pain , nausea , vomiting , jaundice ?

• Associated with any fever, chills , weight©DR.

loss,ELVIS
arthritis ?
 M) History in blood in stools
• onset –

• Duration & progression –

• No. of episodes –

• Hematochezia - Bright red & fresh , frank blood per rectum (bleeding distal to the
ligament of treitz)

• Any feeling of dripping & frank blood ? (*hemorrhoids)

• Aggravates with constipation ?

• Associated with pain ? Mucous discharge in stool ? Malena

©DR. ELVIS
 M) History of blood in stools
• onset –

• Duration & progression –

• No. of episodes –

• Hematochezia - Bright red & fresh , frank blood per rectum (bleeding distal to the
ligament of treitz)

• Any feeling of dripping & frank blood ? (*hemorrhoids)

• Aggravates with constipation ?

• Associated with pain ? Mucous discharge in stool ? Malena

©DR. ELVIS
 *D/D of rectal bleeding
• Hemorroids

• Anal fissure

• Colorectal polyps/cancer

• Inflammatory bowel disease

• Ischaemic colitis

• Complicated diverticular disease

• Vascular malformation
©DR. ELVIS
 N ) History of urine
• Daily amount – *Oliguria in hepato-renal syndrome from cirrhosis of liver

• Colour –

• Frequency –

• Associated with blood (hematuria)– *Urinary tract inj, Intravscular Hemolysis

• Associated with pus / pain / burning sensation ? ----UTI

• Any features of BPH ? E.g- dribbling of urine, narrow stream , feeling of

incomplete voiding of bladder

©DR. ELVIS
 O) Other HOPI
• H/o B- symptoms (lymphoma) – fever , drenching night sweats ,
pruritus after alcohol intake weightloss > 10%

• H/o pedal odema - *malnutrition , CVS disorder, hypoproteinemia

• H/o easy fatigability, weakness , tiredness - *leukemia ,

hemolysis , anemia

©DR. ELVIS
 P) History of other systems (*Important)
• CNS - seizure, altered consciousness (wilson/hepatoencephalopathy)

• Renal – pedal odema , oliguria , facial puffiness *hepatorenal failure

• CVS – Constrictive pericarditis

• RS – cough with sputum (TB ) , in 10% hydrothorax

- Orthopnea in tense ascites ,B/L diaphragm palsy , COPD )

©DR. ELVIS
 4. Menstrual History

- Age at Menarche

- Attained Menopause at -

- Cycles – regular/irregular , frequency, days of flow , volume ,

associated with clot/pain , h/o - intermenstrual/post menopausal
bleed ,

- LMP

©DR. ELVIS
 5. Personal History
• allergy to any medication ? On any medication ?

• Altered Sleep rhythm? Confusion ? Personality changes ? Mood changes (*Encephalopathy

changes)

• Significant weight loss – reason (mouth ulcer) (*malignancy/TB) (loosening of cloths , rings)

• Appetite –

• Addictions – Alcohol / Smoking (at a risk of esophageal ca, colorectal ca, PUD)

• Diet – veg / non-veg/vegan(Vit B12 def)

• Skin Tattoos -

• Sexual history
©DR. ELVIS
 Alcohol history
• Type of drink – beer , wine , gin , vodka , whisky , Rum

• Frequency – daily/weekly/occasionally

• Quantity –

• Units consumption - ____per day or ___per week

• Duration of drinking -

• H/o last binge –

• Reason to stop drinking & sober since when ? , if applicable –

©DR. ELVIS
©DR. ELVIS
 6. Past history
• H/o similar episodes –

• H/o Jaundice/blood transfusion/ surgeries/I.v drug abuse / hematochezia

• H/o leukemia , hemolytic crisis, hepatitis -

• H/o TB/DM/HTN/STD/CAD (on medications or not ,type, regular ? )

• H/o endocrine / cardiovascular / respiratory disorder

• H/o recent travel -

©DR. ELVIS
 7. Family history

• Family tree
• Consanguineous marriage --- Autosomal recessive diseases

• Any history of such illness in family ? * jaundice, liver

disease, or anemia

• Family h/o IBD , Colon ca, autoimmune diseases

©DR. ELVIS
 8) Social history
• Martial status & No. of children –

• Lives with family or alone ?

• Education & occupation –

• Upbringing- complications, schooling , behavioral problem

• Home life – abuse , stress, grief

• Financial condition –

• Home – type , facilities of sanitation , water , waste disposal

• Lifestyle - exercise , leisure activity ,©DR.

hobbyELVIS
, diet
 Summary of History

• ____ year old , ______ (occupation) has come with

C/C___ & symptoms _______ (mention all significant
positive history supporting your diagnosis)
_________With comorbidities HTN/DM . Probably due to
____

• My provisional/Differential diagnosis _____(in

sequence with priority first)

©DR. ELVIS