History Taking for Abdomen Case in General Medicine

- Dr. Ankit Chandra

1. Patient details

• Name –

• Age –

• Gender -
• Hailing from (Address )_____
• Educated up to ___
• Working as a (Occupation)- ______

• Family’s Monthly income / Socio-economic status –

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

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

| Dr. Ankit Chandra

 • Etiology/ cause/ risk factors –

• Complications -
• h/o DM/HTN -

a) History of Pain (SOCRATES)

• Site – localized/ diffuse/ generalized

• Onset– sudden/ Rapid / Gradual

• Character – sharp/constant dull /burning sensation/colicky

• Intensity /Severity -

• Radiation –

• Associated symptoms – vomiting , loose motions

• Timing / Duration, course – episodic/continuous , duration

• Exacerbating & Relieving factors – specific posture , drugs

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 ?

c) History in Dysphagia

• Onset – gradual/abrupt

• Duration –

| Dr. Ankit Chandra

• Progression – chronic / progressive / intermittent

• More for solids or liquids or both ?

• Any feeling of food sticking or fullness of esophagus or associated with heart burn ?
• Painful on swallowing (odynophagia) ?

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? fresh or
altered blood?
• Does the patient have upper abdominal bloating, fullness, or discomfort?
• Are belching and flatulence prominent?
• Does the patient complain of a bad taste in the mouth or coated tongue?
• Has the patient experienced fatigue, somnolence, or headache?
• Drugs - NSAIDs

E) History in vomiting

• Associated/ Preceded with nausea (sensation of feeling sick) –

• Frequency / no. of episode –

• Projectile / Non Projectile type

• Content & quantity – *relation to meals

• Blood stained or Bile stained ?

• Associated with tinnitus, headache , Diarrhea , fever ?
• H/o of any emetic drugs

F ) History in Hematemesis
*Differentiate from Hemoptysis

• No. of episodes –

| Dr. Ankit Chandra

• mixed with food ?
• Fresh blood / altered (*coffee ground)

• Amount of blood –

• Associated with Malena ?

• Ingestion of any drugs - NSAIDs?

*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 ?
• h/o any drug intake - *Rifampicin , INH, OCP , Quinine , Phenol toxicity

H ) History in Fever

• onset –

• Duration & progression –

• Associated with chills & rigor ?

• Evening Rise of temperature ?
• Associated with vomiting , abdomen pain, loose motion ?

I ) History of a Mass per Abdomen

• Onset – sudden/insidious

• Duration –

| Dr. Ankit Chandra

• Site -

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

• Associated with pain, weight loss ?

• Pressure Symptoms– dyspepsia (MCS & ignored), abdominal distention , sense of bloating

after meals & loss of appetite , dull abdomen pain , dyspnea, nausea , vomiting

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 –

K ) History in Constipation

• How often patient used to have have bowel movements before he/she was all right & how
often is now ?(Bowel habits)

• 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 , opiods

L ) History in Diarrhea (acute vs. chronic)

• Frequency of stool
• Volume & quantity of stool

• Time of Occurrence – night or day

| Dr. Ankit Chandra

• Nature & consistency of stool -

• Aggravating & reliving factors – food, drugs

• presence of blood/ Mucous

• Color of stool –

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

• Associated with abdomen pain , nausea , vomiting , jaundice ?
• Associated with any fever, chills , weight loss, arthritis ?

M) History in blood in stools

• onset –

• Duration & progression –

• No. of episodes –

• Hematochezia - Bright red & fresh , frank blood per rectum

• timings – blood in the entire stool ? Or blood at the end of stool ? Streaked blood ?

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

• Aggravates with constipation ?
• Associated with pain ? Mucous discharge in stool ? Malena

N ) History of urine

• Daily amount – *Oliguria in hepato-renal syndrome from cirrhosis of liver

• Colour –

• Frequency –

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

• Associated with pus / pain / burning sensation ?

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

| Dr. Ankit Chandra

 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

P) History of other systems (*Important)

• CNS - seizure, altered consciousness (wilson/hepatoencephaopathy / gaucher type 2 )

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

• CVS – Constrictive pericarditis (*ascitis precox)

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

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

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 ,

- Last LMP –

5. Personal History
• allergy to any medication ? On any medication ?

| Dr. Ankit Chandra

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

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

• Appetite –

• Addictions – Alcohol / Smoking

• Diet – veg / non-veg/vegan ,

• Skin Tattoos -
• Sexual history

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 –

• CAGE Questionnaire -

6. Past history

• H/o similar episodes –

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

| Dr. Ankit Chandra

 • H/o malaria/kala azar, 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 -

7. Family history
• Any history of such illness in family ? * jaundice, liver disease, or anemia (especially when
requiring splenectomy)
• Family h/o IBD , Colon ca, autoimmune diseases

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 , hobby , diet

| Dr. Ankit Chandra

 • Community support -
• Sexual history -

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)

Buy Subjectwise Question Banks to Pass MBBS exams

(Available for all the 19 subjects now in kindle store !!)
- Amazon/kindlestore/ankitsuniyal

To Follow
Facebook – facebook.com/ankitsuniyalvids
Twitter – suniyal3151
Email – suniyal3151@gmail.com
Youtube – Ankit Suniyal Vids (AS)

| Dr. Ankit Chandra