The History

History taking in older patients with abdominal pain should follow the same general sequence and rules as in younger patients. Unfortunately, an accurate history may be difficult to obtain in this age group. Serious abdominal disease may cause an acute mental status change or distract the patient's attention. Memory deficits or underlying dementia can obscure important aspects, such as the time and nature of the onset of pain.8 The noise and pace of the ED are often inconsistent with the needs of the older patient who is attempting to relay historical information about his or her abdominal pain. The following historical aspects should be covered:

• Time of Onset: Pain awakening the patient from sleep should always be considered significant.

• Mode of Onset: A sudden, severe pain should alert the physician to the possibility of serious disease, including a ruptured abdominal aortic aneurysm, aortic dissection, superior mesenteric artery embolus, perforation of a peptic ulcer, or volvulus. It is equally important to remember that these entities may present without a sudden onset. For example, in one prospective series of patients over the age of 70 with perforated ulcers, only 47 percent reported a sudden onset of pain.6

• Progression since Onset: Steady improvement is reassuring, worsening is not.

• Location of the Pain: In general, this seems to be reliable in the elderly. For example, appendicitis in this age group, although diagnostically difficult, generally presents with right-lower-quadrant pain.9

• Character of the Pain: Severe pain should be taken as an indicator of serious disease. Think of mesenteric ischemia, perforation of a gastric ulcer, vascular accidents, and volvulus.

• Referral or Radiation of the Pain: As with location, this aspect of abdominal pain should not change with aging. For example, the referral pattern is helpful in

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diagnosing older patients with biliary tract disease.8

• Precipitating and Relieving Factors: Pain with movement suggests irritation of the parietal peritoneum. The results of any self-treatment should be determined.

• Prior Episodes: This generally suggests a medical cause with the notable exceptions of mesenteric ischemia (intestinal angina) and cholecystitis. 10

• Associated Symptoms: Anorexia, vomiting, bowel habits, and urinary symptoms are key areas to cover. In general, pain almost always precedes vomiting in surgical causes of abdominal pain, while the converse is true in 75 percent of patients with gastroenteritis or a nonspecific cause of abdominal pain. 1

• Further History: A detailed review of systems is desirable to seek other causes of abdominal pain, especially those of a cardiopulmonary nature. Do not neglect a careful review of medications including over-the-counter nonsteroidal anti-inflammatory agents. Underlying alcohol abuse must also be a consideration in this age group.

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