Abdominal Pain Assessment

Abdominal Pain Assessment - Pain Interrogation

• 📌 Use SOCRATES for systematic pain history:
  • Site: Location? Localized/diffuse?
  • Onset: Sudden (perforation, ischemia) or gradual (inflammation)?
  • Character: Sharp, dull, colicky, burning?

    ⭐ Visceral pain: dull, poorly localized, midline (bilateral innervation). Parietal pain: sharp, well-localized, lateralized.

  • Radiation: To back, shoulder (Kehr's sign), groin?
  • Associated symptoms: N/V, fever, bowel changes (diarrhea/constipation), jaundice.
  • Timing: Duration, frequency, pattern (constant, intermittent)?
  • Exacerbating/Relieving factors: Food, position, medications?
  • Severity: Pain scale (0-10); effect on activity.

Abdominal Pain Assessment - Palpation Powwow

• Method: Light palpation before deep. Assess tenderness (superficial/deep), guarding, rigidity.
• Guarding Types:
  • Voluntary: Conscious tensing; often distractible.
  • Involuntary (Rigidity): Persistent muscle spasm; suggests peritonitis.
• Key Palpation Signs:
  • Rebound Tenderness (Blumberg's): Pain on quick withdrawal; peritonitis.
  • Murphy's Sign: Inspiratory arrest on deep RUQ palpation; acute cholecystitis.
  • Rovsing's Sign: RLQ pain with LLQ palpation; appendicitis.
  • Psoas Sign: Pain on passive hip extension; retrocecal appendicitis.
  • Obturator Sign: Pain on passive internal hip rotation; pelvic appendicitis.

⭐ Carnett's sign (↑ pain on tensing abdominal muscles) suggests abdominal wall pain, not visceral.

Abdominal Pain Assessment - Region Riddles

Localize pain to narrow differentials. Key associations:

• Epigastric Region:
  • Peptic Ulcer Disease (PUD), Gastritis, GERD
  • Acute Pancreatitis, Myocardial Infarction (MI)
• Right Upper Quadrant (RUQ):
  • Cholecystitis, Cholelithiasis, Cholangitis
  • Hepatitis, Fitz-Hugh-Curtis syndrome
• Left Upper Quadrant (LUQ):
  • Splenic disorders (infarct, rupture)
  • Gastritis, Pancreatitis (tail)
• Periumbilical Region:
  • Early Appendicitis, Gastroenteritis
  • Small Bowel Obstruction (SBO)
  • Abdominal Aortic Aneurysm (AAA)
• Right Lower Quadrant (RLQ):

  ⭐ RLQ pain: classic for appendicitis; consider Crohn's, ectopic pregnancy, ovarian torsion, Meckel's diverticulitis. Also: PID, urolithiasis.

• Left Lower Quadrant (LLQ):
  • Diverticulitis, Sigmoid Volvulus
  • Ectopic pregnancy, Ovarian torsion
  • PID, urolithiasis
• Suprapubic Region:
  • Acute Cystitis, Prostatitis
  • Pelvic Inflammatory Disease (PID), Uterine pathology

Abdominal Pain Assessment - Alarm Bells

Key indicators requiring urgent evaluation:

• Vitals: Hypotension, tachycardia, fever
• Exam: Peritonism (rigidity, rebound), distension, pulsatile mass
• History: Sudden onset, severe pain, syncope, persistent vomiting, hematemesis, melena, age >50 with new onset

⭐ Sudden severe pain ('thunderclap'), hemodynamic instability, peritonism (rigidity, rebound), or pulsatile mass are RED FLAGS requiring urgent action.

Abdominal Pain Assessment - Diagnostic Dash

• Initial Labs: CBC, CMP, LFTs, Amylase/Lipase, UA, Urine pregnancy test (females).
• Imaging:
  • X-ray (obstruction, free air).
  • Ultrasound (gallbladder, GYN, appendicitis in children/pregnancy).
  • CT scan (most common, high yield for many conditions).

⭐ Serum lipase is more specific than amylase for acute pancreatitis and remains elevated longer. Beta-hCG is crucial in all women of childbearing age.

High‑Yield Points - ⚡ Biggest Takeaways

• Visceral pain: dull, poorly localized, midline; Parietal pain: sharp, localized, worse with movement.
• Referred pain: felt distant to organ (e.g., Kehr's sign for splenic rupture).
• Acute cholecystitis: Murphy's sign (RUQ inspiratory arrest).
• Appendicitis: McBurney's point tenderness, Rovsing's sign, Psoas/Obturator signs.
• Red flags: sudden severe pain, hemodynamic instability, peritonism (rigidity, rebound).
• Consider ectopic pregnancy in females of childbearing age with lower abdominal pain.