abdo pain

onset

hours days weeks months years
sudden gradual

new?

new issue previously known issue

intensity

mild mild-moderate moderate moderate-severe severe

frequency

single episode constant intermittent daily few times a week few times a month

duration

few minutes less than an hour few hours most of the day few days

status

improving unchanged resolved gradually worsening significant worsening

HPI

location

general abdomen RUQ epigastric LUQ periumbilical RLQ LLQ suprapubic R flank L flank

radiation

none entire abdomen chest RUQ epigastric LUQ periumbilical
RLQ LLQ suprapubic R flank L flank R back L back R groin L groin

quality

burning debilitating dull pressure superficial sharp throbbing cramping stabbing

timing

daytime upon awakening night time pre menstrual

aggravated by

nothing post prandial fatty foods certain foods walking/standing lying down

relieved by

nothing passing BM time lying down heartburn rx OTC meds heat

abdo/GI

– flatus in past 24h +
last BM: within 1 day within 3 days within 1 week over 1 week

↓ normal ↓

throat

+ sore throat – + hoarseness – + trismus – + dysphagia/odynophagia –

resp

+ cough – + sputum – + hemoptysis – + dyspnea – + wheezing –

+ frequency – + urgency – + dysuria – + hematuria – + incontinence –
+ cloudy urine – + weak stream – + nocturia –

M genital

+ discharge – + hernia – + masses – + STI concerns –

F genital

+ dyspareunia – + dryness – + discharge – + pruritus – + STI concerns –

inspection

normal
distention: mild moderate significant

palpation

normal
tender: general abdomen RUQ epigastric LUQ periumbilical RLQ LLQ suprapubic R flank L flank
non peritonitic no hernias
+ CVA tender –

signs

+ murphy – + mcburney – + rovsing – + obturator –

genitals

declined normal

U/A

+ hematuria – + leuks – + nitrites –

other

Assessment:

GERD biliary colic appendicitis pancreatitis constipation
uncomplicated UTI pyelonephritis renal colic IBS mittelschmerz uncomplicated diverticulitis functional NYD

no red flags

details

Plan

investigations

AXR CXR colonoscopy EGD CT US
symptoms diary

referral

GI gen surg urology gyne

abx PPI H2 blocker peg 3350 fiber supplement

follow-up

2-4 weeks PRN only after investigations

RTC

instructions given

other

ABDO PAIN

S/

O/

A/

P/