Historical Features

What follows assumes that the patient is sufficiently stable to allow for a detailed history and goal-directed examination. Historical data can be conveniently divided into attributes of pain, associated symptoms, and past history.

PAIN ATTRIBUTES The principal characteristics of abdominal pain include location, quality, severity, onset, duration, aggravating and alleviating factors, and change in any of these variables over time.

ASSOCIATED SYMPTOMS These can be subdivided into one of the four main organ systems that are involved in intraabdominal pain, as shown in Tab!e„68-1.

Gastrointestinal Symptoms Anorexia, nausea, and vomiting (unless bloody) are among the least helpful symptoms for specific diagnosis. For example, vomiting has been reported in over 40 percent of patients with salpingitis, and in over 60 percent of patients with renal colic. Lower gastrointestinal (GI) symptoms such as nonbloody diarrhea or constipation are similarly too insensitive and nonspecific to significantly alter the probability of a GI cause of abdominal pain.

Genitourinary Symptoms The hallmark of abdominal pain of genitourinary (GU) origin is the concomitant development of some, often subtle, alteration in micturition—e.g., dysuria, frequency, urgency, hematuria, incomplete emptying, or incontinence (usually overflow). On occasion, non-GU pathology develops in organs contiguous to the GU system, giving the appearance of an intrinsic GU problem. For example, an inflamed appendix lying across the bladder might cause urinary frequency.

Gynecologic Symptoms Distinguishing GI from gynecologic (GYN) causes of acute abdominal pain is one of the most challenging clinical dilemmas in emergency practice. A thorough gynecologic history is indicated, including menses, mode of contraception, fertility, sexual activity, sexually transmitted diseases, vaginal discharge, recent dyspareunia, and a past gynecologic history, including pregnancies, deliveries, abortions, ectopic pregnancies, cysts, fibroids, pelvic inflammatory disease, and laparoscopy.

Vascular Symptoms History of myocardial infarction (MI), other ischemic heart disease or cardiomyopathy, atrial fibrillation, anticoagulation, congestive heart failure, peripheral vascular disease, or a family history of aortic aneurysm are all pertinent historical features in older patients.

PAST MEDICAL HISTORY This includes a history of recent/current medications (including nonsteroidal anti-inflammatory drugs and antibiotics), past hospitalizations, in- or outpatient surgeries, diabetes, other chronic diseases [including human immunodeficiency virus (HIV) status and risk factors], central nervous system (CNS) disease (such as multiple sclerosis), and any history of recent trauma. A social history that includes habits (tobacco, alcohol, and other drug usage), occupation, possible toxic exposures, and living circumstances (e.g., homeless, residing in an unheated dwelling, with no access to running water, living alone, other family members ill with similar symptoms) provides important background and a context within which to place the presenting complaint of acute abdominal pain.

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