Abdominal pain
In an abdominal pain workup, gather and document site, onset and character, bowel and urinary symptoms, gynecological history where relevant, examination findings, results, and the red flags.
General and abdominal: These presentations have a wide differential, so you read results from several sources together.
Key takeaways
- Record the site, onset and character before the examination.
- Ask about bowel, urinary and gynecological symptoms.
- Document peritoneal signs and hemodynamic status, present or absent.
What this presentation is
Abdominal pain has gastrointestinal, urological, gynecological, vascular and referred causes. Acute and chronic pain call for different workups.
Results and imaging reports already in the record often narrow the list. Gather them before ordering more.
Gather these sources first
- The referral and previous surgical or gastroenterology letters
- Complete blood count, liver function, renal function and inflammatory markers
- Amylase or lipase if done
- Urinalysis and a pregnancy test where relevant
- Ultrasound, CT and endoscopy reports
- The medication list, including anti-inflammatory drugs
Document these history questions
- Site, onset, character and radiation
- Timing, and relation to food and bowel movements
- Change in bowel habit and rectal bleeding
- Vomiting, urinary symptoms and fever
- Gynecological history and possible pregnancy
- Previous abdominal surgery
- Weight change and appetite
Record these findings
- Temperature, pulse and blood pressure
- Site of tenderness, guarding and rebound
- Masses, organomegaly and hernial orifices
- Lab results with dates
- Imaging findings as reported
Ask about these red flags
Record each one as present or absent. Your local pathway decides what happens when one is present.
- Peritoneal signs
- Hemodynamic instability
- Gastrointestinal bleeding
- Persistent vomiting
- Jaundice
- A pulsatile abdominal mass
- Unintentional weight loss or difficulty swallowing
Put these in the assessment draft
- The pain described by site, onset and character
- A ranked differential with the reasoning
- The examination and results that bear on it
- The red flags asked about and the answers
- A plan with investigations, referral and safety-netting advice
How Workup Desk helps
Add the results, imaging reports and earlier letters to the workspace. Ask which investigations have already been done and what each concluded.
Draft the assessment or a referral letter and edit it. Check each quoted result against its source.
Frequently asked questions
Why record a negative pregnancy test?
Pregnancy changes the differential and the choice of imaging. A recorded result tells the next reader it was considered.
General guidance on what to gather and document, not advice about any individual patient. Local guidelines and your clinical judgment govern.