How to obtain a detailed patient history for abdominal pain

After you have determined the patient’s chief complaint and have obtained a history of present illness, you should obtain a detailed history from a patient presenting with abdominal pain. Information gathered in the history can help focus the diagnosis and guide you when you’re performing a physical exam.

A detailed history is imperative for narrowing down your assessment and determining the plan of action you’ll take with your patient. Let’s discuss the questions to ask your patient when taking a detailed history. These questions should focus on aspects that are most pertinent to abdominal pain or symptoms.

A patient’s history is commonly organized into four sections:

1. Past medical history
2. Past surgical history
3. Family history
4. Social history

The past medical history is a sum of the patient’s past and current medical records. When making your inquiries, begin by asking the patient about their medical history. For example, ask if they have any past or current medical problems.

During this section of questioning, it is important to get all the information in their medical history. But, pay close attention if the patient mentions a history of sickle cell anemia, gastrointestinal problems, liver disease, or cancer.

Does the patient’s medical history include gastrointestinal problems such as gastroesophageal reflux disease (GERD), diverticular disease, a gastrointestinal bleed, or gallstones? Does it include liver diseases such as cirrhosis, fatty liver, or hepatitis?

Have they ever had any history of cancer? If the answer is yes, make sure to clarify what type of cancer to identify which organ system was involved.

It is also important to inquire about completed screening exams including colonoscopies, mammograms, pap smears, prostate-specific antigen (PSA) levels, and prostate exams.

The patient’s past surgical history includes any previous surgery; all surgeries, whether laparoscopic or open, are relevant. But, focus on abdominal surgeries such as those involving the bowel, colon, stomach, liver, or spleen. As well, don't forget to ask about gynecological or urological surgeries such as caesarian section, hysterectomy, cystectomy, nephrectomy, or prostatectomy.

It is also important to ask about the patient’s family history since some conditions may run in the family. Patients often forget which types of cancers their family may have had, so it is helpful to remind them. A family history of cancers such as colon cancer (especially in a first-degree relative) puts the patient at a higher risk. With these patients, it is important to discuss colonoscopy screening.

Gastrointestinal conditions such as colonic polyps and inflammatory bowel diseases (e.g., Crohn's disease and ulcerative colitis) can also have a genetic component. So, it is important to ask about a family history of these conditions.

The social history is also important for the abdominal exam. Factors such as alcohol use, tobacco smoking, drug use, diet, and living situations could be associated with the patient’s diagnosis.

Alcohol use

Alcohol can worsen conditions such as GERD and gastritis. And, it can cause liver diseases and pancreatitis. A patient who suffers from long-term alcohol abuse may also have hepatomegaly on abdominal palpation.

Tobacco smoking

Tobacco smoking is associated with several gastrointestinal problems. It can worsen GERD and gastritis and is a risk factor for pancreatic cancer.

Drug use

Drug use can also be associated with abdominal symptoms. Marijuana can cause cannabinoid hyperemesis syndrome, which consists of nausea, vomiting, and vague abdominal pain. Cocaine use can lead to mesenteric ischemia as well as gastric, duodenal, or intestinal perforation.

Opioids can cause constipation, nausea, and ileus (a slowing of the bowel). Chronic opioid use can cause narcotic bowel syndrome which is associated with increased abdominal pain despite continued or increased use of pain medicines.

Diet

The patient’s diet also has an important impact on abdominal pain, and hints at the patient’s gut health. For example, a patient who eats mostly fried and greasy foods is more likely to develop gallstones. A patient who eats very little fiber is more prone to diverticular disease or colonic dysmotility.

Living situations

A patient’s living situation provides insight into their overall health. It is important to assess if the patient has access to food. For example, someone who is ill and lives with family or a spouse would likely have help with cooking nutritious meals compared to someone who lives alone or is homeless.

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