Neurological motility disorder: stroke; movement disorders (Parkinson’s disease, progressive supranuclear palsy); amyotrophic lateral sclerosis; multiple sclerosis; bulbar palsy; brainstem tumour; pseudobulbar palsy

Striated muscle disease: myasthenia gravis; myotonic dystrophy; polymyositis; dermatomyositis; inflammatory myopathy; muscular dystrophy

Reduced salivary flow leading to dry mouth (xerostomia): Sjogren’s syndrome; anticholinergics; antihistamines; ACE inhibitors; alpha-adrenergic blockers

Structural lesions: inflammatory: pharyngitis, tonsillar abscess; head and neck tumours; pharyngeal diverticula; ulcerative stomatitis; painful glossitis; anterior marginal cervical osteophytes (especially with diffuse idiopathic skeletal hyperostosis)

Metabolic: hypothyroidism; hyperthyroidism; steroid myopathy

Solids & liquids (neuromuscular motility disorders)

Solids only (mechanical obstruction)

Strictures

Extrinsic compression: bronchial carcinoma; mediastinal lymph nodes; vascular compression; cervical osteoarthritis with vertebral osteophytes; mediastinal tumours

Oesophageal web

Foreign bodies (especially with pre-existing gastrointestinal abnormalities, such as diverticula, webs, rings): food bolus impaction; disc or button battery; coin (oesophageal coins are seen in a coronal alignment on an AP xray); toy parts, marbles

Extrinsic compression: goitre with retrosternal extension; mediastinal tumours; large left atrium

Oesophagitis: infective (candidal; herpetic; cytomegalovirus); pill-induced (associated with oesophageal dysmotility, stricture or extrinsic compression) (tetracycline, doxycycline; potassium chloride; NSAIDs, aspirin; alendronate); corrosive (caustic ingestion); radiation induced

Oesophageal ulcer

Evidence of weight loss

Anaemia

Hoarseness of voice

Oral ulceration; signs of candidiasis

Cervical lymphadenopathy

Bulbar signs

Chest signs

Oedema of the lips, tongue and palate

Oropharyngeal burns

Drooling of saliva

Dysphagia

Nausea and vomiting

Haematemesis

Shortness of breath

Stridor

Abdominal pain

Drooling of saliva

Difficulty in initiating swallowing

Nasal regurgitation

Choking or coughing while feeding

Food sticking in the throat

Nasal tone to speech

Aspiration, with recurrent pneumonia

Solids handled better than liquids

Difficulty initiating swallowing

Cough and choking during and after swallowing

Nasal regurgitation of liquids

Hesitancy and repeated attempts at the inititation of swallowing

Food sticking in throat

Nasal speech

Changes in the character of the voice

Constant drooling of saliva

Sensation of food sticking in chest or throat after swallowing

Recurrent pneumonia

Gastro-oesophageal reflux disease: heartburn; belching; sour regurgitation; waterbrash

Progressive painless dysphagia

Unintentional weight loss

Persistent vomiting

Haematemesis

Hoarseness of voice

Systemic symptoms: fever, night sweats

Bulbar neurological signs

Cervical lymphadenopathy

Age >70 years

Smoking

Alcohol consumption (SCC)

Dietary factors

Barrett oesophagus

Gastro-oesophageal reflux disease (adenocarcinoma)

Excessive ingestion of very hot liquids (SCC)

Caustic ingestion (SCC)

Achalasia (SCC)

Plummer-Vinson syndrome (SCC)

All: FBC, U&E, LFTs, bone profile, CXR (mediastinal widening, absence of gastric air bubble, extrinsic mass)

Oropharyngeal: direct laryngoscopy; video fluoroscopy

Oesophageal: endoscopy; barium swallow; oesophageal manometry

Gastrointestinal: heartburn; regurgitation; waterbrash; globus sensation of lump in neck or throat; dysphagia (erosive oesophagitis; peptic stricture (intermittent solid food dysphagia in a patient with heartburn); adenocarcinoma of oesophagus); odynophagia; hiccups; epigastric pain, dyspepsia; vomiting; erosion of dental enamel

Pulmonary: chronic nocturnal cough; asthma; sleep apnoea; aspiration; recurrent pneumonia; interstitial pulmonary fibrosis; acute life-threatening episodes

ENT: sore throat; hoarseness; laryngitis; chronic sinusitis; vocal cord granulomas; sub-glottic stenosis

Atypical chest pain

Dystonic movements: Sandifer’s syndrome (gastro-oesophageal reflux associated with torsional dystonia of the head, neck, eyes and trunk, and opithostonic posturing)

Smoking

Alcohol ingestion

Obesity

Drugs: NSAIDs; calcium channel blockers; nitrates; benzodiazepines

Systemic disease: diabetes mellitus with autonomic neuropathy; scleroderma

Sleep apnoea

Infectious oesophagitis

Gastrooesophageal reflux/stricture

Pill-induced ulceration

Radiation oesophagitis

Caustic stricture

Foreign body

Cancer

Fungal infections: candida albicans

Viral infections: herpes simplex; cytomegalovirus; Epstein-Barr virus

Bacterial infections

Protozoal infections

Pain in dermatome distribution

Well localised

Sharp

Clear onset

Referred pain in embryonic distribution

Poor localisation

Dull and aching

Insidious onset

Aortic aneurysm: leaking; ruptured

Aortic dissection

Early appendicitis

Bowel obstruction

Diabetic gastric paresis; diabetic ketoacidosis

Gastroenteritis (vomiting precedes abdominal pain)

Heavy metal poisoning

Hereditary angioedema

Mesenteric ischaemia

Volvulus

Metabolic disorder: Addisonian crisis, ketoacidosis (diabetic, alcoholic), acute intermittent porphyria (attacks of severe diffuse abdominal pain, associated with nausea and vomiting, constipation, muscle weakness, urine retention, and sometimes confusion, hallucinations and seizures; increased urine delta-aminolaevulinic acid and porphobilinogen; atatcks may be precipitated by hormonal changes, drugs, reduced calorie intake, alcohol, and emotional stress), uraemia

Opioid withdrawal

Pancreatitis

Perforated bowel

Peritonitis from any cause

Sickle cell crisis

Malaria

Familial Mediterranean Fever

Spiegelian, incisional hernia

Rectus sheath haematoma (abdominal wall mass with bruising; risk factors include old age, anticoagulant therapy, trauma, injection procedures, physical exercise, and raised intra-abdominal pressure fro coughing, sneezing or vomiting)

Muscle strain

Biliary disease: Biliary colic; acute cholecystitis (Murphy’s sign of inspiratory arrest due to pain on inspiration during right subcostal palpation with hand or ultrasound probe; jaundice in 20–25% cases); choledocholithiasis, cholangitis

Hepatic disease: acute hepatitis; liver abscess; hepatic congestion; liver tumour

Perihepatitis (Fitzhugh-Curtis syndrome): may be associated with signs of salpingitis

High retrocaecal appendicitis; appendicitis complicating pregnancy

Perforated duodenal ulcer

Perinephritis

Pulmonary: right lower lobe pneumonia; pleuritis; pulmonary embolism; empyema

Myocardial ischaemia

Herpes zoster

Increasing age

Female gender

Obesity

Pregnancy and multiparity

Rapid weight loss (>1.5 kg/week), including during treatment for morbid obesity

Hypertriglyceridaemia

Low LDL cholesterol

Diabetes mellitus

Drugs: oestrogens, octreotide, ceftriaxone

Ileal disease (Crohn’s disease; terminal ileal resection/ bypass)

Primary biliary cirrhosis

Viral hepatitis

Budd-Chiari syndrome

Hepatic malignancy

Biliary colic

Choledocholithiasis

Cholangitis

Cholecystitis

Pre-eclampsia or eclampsia

HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (third trimester)

Acute fatty liver of pregnancy

Hepatic haemorrhage or rupture

Symptomatic choledochal cysts

Splenic: splenic rupture/distension; splenic infarction; splenomegaly (spontaneous splenic rupture can present with referred left shoulder pain from diaphragmatic irritation-Kehr’s sign, and a tender left upper quadrant mass-Ballance’s sign, and is associated with infections (infectious mononucleosis and malaria) and haematological malignancy (lymphoma and leukaemia)

Ruptured splenic artery aneurysm

Gastritis

Perforated gastric ulcer

Jejunal diverticulitis; diverticulitis affecting the splenic flexure

Pancreatitis

Pulmonary: left lower lobe pneumonia; pleuritis; empyema

Cardiac: pericarditis; myocardial ischaemia

Herpes zoster

Colonic: acute appendicitis; acute enterocolitis; caecal diverticulitis; colonic obstruction; torsion of appendices epiploicae; epiploic appendagitis

Small bowel: Crohn’s disease (terminal ileitis); Meckel’s diverticulitis; small bowel obstruction; intusussception (triad of vomiting, abdominal pain and currant jelly stools)

Foreign body perforation

Mesenteric adenitis

Perforated peptic ulcer

Gynaecological: ovarian cyst accident (including mittelschmerz)- rupture, torsion; endometriosis; pelvic inflammatory disease(salpingitis); ectopic pregnancy

Cholecystitis

Vascular: aortic aneurysm: leaking; ruptured; ruptured iliac artery aneurysm

Renal: renal/ureteric colic; pyelonephritis

Psoas abscess

Inguinal hernia: incarcerated; strangulated

Testicular torsion

Seminal vesiculitis

Rectus sheath haematoma

Herpes zoster

Colonic: diverticulitis (sigmoid); acute appendicitis (with situs inversus); perforated colonic cancer; Crohn’s colitis; ischaemic colitis; colonic obstruction

Vascular: aortic aneurysm: leaking; ruptured; ruptured iliac artery aneurysm

Gynaecological: ovarian cyst accident (including mittelschmerz),-torsion, rupture); endometriosis;pelvic inflammatory disease(salpingitis); ectopic pregnancy

Renal: renal/ureteric colic; pyelonephritis

Psoas abscess

Testicular torsion

Inguinal hernia: incarcerated; strangulated

Seminal vesiculitis

Rectus sheath haematoma

Herpes zoster

Viral infection

Parasitic infestation

Gastroenteritis

Mesenteric adenitis

Ovulatory pain

Lesions of appendices epiploicae of colon

Intra-thoracic: inferior ST elevation myocardial infarction; pericarditis; lower lobe pneumonia; pulmonary embolism; oesophageal disease

Endocrine/ metabolic: diabetic ketoacidosis; acute adrenocortical insufficiency; acute intermittent porphyria; hyperlipidaemia; Familial Mediterranean Fever

Drug induced: opioid withdrawal; lead poisoning

Haematological: sickle cell crisis; acute leukaemia

Central nervous system: pre-eruptive phase of herpes zoster; spinal nerve root compression

Hollow viscus perforation: stomach (gastric ulcer; gastric cancer); duodenum (duodenal ulcer); small bowel (mesenteric ischaemia and infarction); colon (divericulitis; cancer; inflammatory bowel disease); appendix (appendicitis); gallbladder (cholecystitis)

Abdominal trauma: blunt; penetrating

Foreign body ingestion

Anastomotic leakage

Spontaneous bacterial peritonitis: ascites from portal hypertension; nephrotic syndrome

Pelvic inflammatory disease

Site and duration

Onset: sudden versus gradual; sudden onset suggests a vascular emergency (mesenteric ischaemia; ruptured abdominal aortic aneurysm), volvulus, intestinal perforation or torsion of hollow viscus

Character: sharp, dull, aching, colicky, burning

Radiation: shoulder, back, groin or testicle

Timing: intermittent, constant

Exacerbating (aggravating factors): movement (worsens pain in peritonitis), position, food, medications, and alleviating factors: rest.

Severity

Vital signs; tachypnoea may be related to metabolic acidosis, hypoxaemia, or catecholamine-induced pain response; signs of hypovolaemia: tachycardia, postural hypotension

Localisation of maximal tenderness and guarding

Signs of peritonitis: tenderness, guarding (abdominal wall rigidity), percussion tenderness, rebound tenderness (gentle depression of the abdominal wall for 15 to 30 minutes, followed by sudden release of pressure), generalised ileus, fever

Specific signs: Carnett’s sign: increased pain on tensing abdominal wall when a supine patient lifts the head and shoulders off the bed; Murphy’s sign: inspiratory arrest on deep palpation of right upper quadrant; psoas sign (passive hip extension is painful, with the patient in the lateral decubitus position); Rovsing’s sign (pressure in the left lower quadrant produces rebound pain in the right lower quadrant on release of the pressure); obturator sign (flexion with external and internal rotation of the hip is painful)

Abdominal mass

Aortic tenderness or enlargement (bedside ultrasound may be useful)

Hernial orifices

External genitalia

Bowel sounds: absent; normal; hyperactive; tinkling

Rectal examination

Bimanual pelvic examination

Difficulty in obtaining a history caused by impaired cognitive function (eg dementia)

Atypical presentations

Lack of typical clinical findings (eg peritonitis without peritonism)

Multiple co-morbidities

Medications that block physiological responses leading to difficulty in assessment (eg beta-blockers)

Decreased immune function, leading to increased severity of disease

Perforated hollow viscus: perforated peptic ulcer

Massive haemorrhage: spontaneous splenic rupture; leaking abdominal aortic aneurysm; ruptured ectopic pregnancy

Acute arterial occlusion: mesenteric accident (superior mesenteric artery embolism/ thrombosis, mesenteric venous thrombosis, non-occlusive mesenteric ischaemia); strangulation obstruction

Third space losses of fluid: acute pancreatitis

Cardiac: acute inferior STEMI

Trauma: penetrating; blunt (liver, spleen)

Vascular accident: ruptured aneurysm of abdominal aorta, splenic artery, or iliac artery

Gynaecological: ruptured ectopic pregnancy; ruptured ovarian cyst (follicular cyst; endometriotic cyst)

Ruptured intra-abdominal neoplasm: hepatocellular carcinoma; hepatic adenoma; pelvic tumours (malignant ovarian masses; uterine sarcomas)

Spontaneous rupture of spleen

Anticoagulant therapy

Cardiac: inferior STEMI; congestive heart failure with hepatic congestion

Pulmonary: lower lobe pneumonia; pulmonary embolism

Triad of abdominal, flank or back pain, acute hypotension and pulsatile abdominal mass; a tender aneurysmal mass is indicative of an aortic emergency

Ureteric colic

Rupture into inferior vena cava (aorto-caval fistula): high-output congestive heart failure

Rupture into duodenum (aorto-duodenal fistula): upper gastrointestinal bleeding

Acute testicular pain and bruising

Inguinoscrotal mass mimicking hernia

Rupture into left renal vein: massive haematuria

Iliofemoral venous thrombosis from ilio-caval compression

Acute lower limb ischaemia

Chronic contained rupture, with lumbar neuropathy

Duodenal compression

Hydronephrosis

Ureteric obstruction and renal pain

Thrombo-embolic phenomena: femoral; popliteal; microemboli(trash foot: tip necrosis of toes; small punctate pretibial ischaemic lesions

Acute thrombosis, resembling saddle embolus

Level of diaphragm 2.5 cm

Level of renal arteries 2 cm

Bifurcation 1.5–2 cm

Iliac arteries just distal to the bifurcation 1 cm

Acute right upper quadrant or loin pain: retro-caecal or retro-colic appendicitis

Gastroenteritis: diarrhea and vomiting: pre-and post-ileal appendicitis

Acute right lower quadrant pain with psoas irritation

Acute small bowel obstruction

Dysuria and pyuria; microscopic haematuria: sub-caecal and pelvic appendicitis

Venous blood: full blood count, urea and electrolytes, CRP, liver function tests (right upper quadrant pain), amylase/lipase, glucose; blood gas analysis

12 lead ECG

Ultrasound/CT

Urine dipstick

Urine beta-HCG (all women of child bearing age)

Renal: pyelonephritis; calculus; neoplasm; infected obstructed kidney; abscess; infarction; pelvi-ureteric obstruction

Aortic: leaking aneurysm; dissection

Radiculopathy

Muscle strain

Herpes zoster

Retroperitoneal fibrosis

Acute pancreatitis; acute exacerbation of chronic pancreatitis

Pancreatic cancer

Ruptured ectopic pregnancy

Peritonitis

Perforated hollow viscus (peptic ulcer disease with perforation

Intestinal obstruction

Mesenteric ischaemia/infarction

Biliary tract disease; acute cholecystitis; choledocholiathiasis

Aortic dissection

Acute appendicitis

Acute salpingitis

Salivary gland disease

Pregnancy

Tumour

Burns

Renal disease: chronic kidney disease

Diabetes ketoacidosis

Macroamylasaemia

Sudden onset of upper abdominal pain, radiating to the mid-thoracic area of the back; continuous, severe, reduced on sitting up or leaning forwards