Abdominal pain is one of those classic "bread and butter" topics in primary care, but it can be a real diagnostic challenge because almost anything from the chest to the pelvis can be the culprit! For the UKMLA AKT, the goal is to quickly differentiate between benign, self-limiting conditions and the "must-not-miss" surgical or medical emergencies.

Let's start by looking at some key lessons that break down the systematic approach to abdominal pain.

When you're in the GP surgery, your assessment needs to be efficient. I like to think of it as a funnel: start broad with the history, then narrow it down with the physical exam and red flags.

1. The Systematic History (SOCRATES)

The history is where you'll get 80% of your diagnosis. Use the SOCRATES acronym, but pay special attention to:

• Onset: Sudden (perforation, torsion, vascular) vs. gradual (inflammatory).
• Associated Symptoms: Fever, vomiting, change in bowel habit, urinary symptoms, or gynae history (always ask about the Last Menstrual Period!).
• Extra-abdominal causes: Don't forget that an inferior MI, pneumonia, or DKA can all present as abdominal pain.

2. Physical Examination

• Inspection: Scars (previous surgery = risk of obstruction), distension, or visible pulsations.
• Palpation: Start away from the pain. Look for guarding (voluntary) vs. rigidity (involuntary/peritonitis) and rebound tenderness.
• Special Tests: Murphy’s sign (cholecystitis), Rovsing’s sign (appendicitis).
• Don't forget: Check the hernial orifices and consider a PR or PV exam if the history points that way.

3. Red Flags (The "Must-Not-Miss")

These are the features that should make you consider an urgent referral or admission:

==Abdominal Pain Red Flags==

• Hemodynamic instability: Tachycardia, hypotension (think AAA or ectopic pregnancy).
• Signs of peritonitis: Rigidity, guarding, "pain with every bump in the road."
• Systemic upset: High fever, rigors, or jaundice.
• Suspected Cancer (NICE NG12): Unintentional weight loss, iron-deficiency anemia, or a palpable mass.
• Bowel Obstruction: Absolute constipation (no flatus), faeculent vomiting, and tinkling bowel sounds.

To help you visualize the differential diagnoses based on where the patient is pointing, let me pull up a helpful diagram and a comparison table.

This diagram is a great visual summary of how we categorize abdominal pain by quadrant. It's a high-yield way to organize your differential diagnosis for the AKT.

To wrap up your systematic assessment, you'll need to consider your initial investigations. In primary care, these are often "rule-out" tests:

• Bedside: Urine dipstick (UTI/renal colic), Pregnancy test (mandatory in any woman of childbearing age!), and basic obs (BP, HR, Temp).
• Bloods: FBC (infection/anemia), CRP (inflammation), LFTs (biliary), Amylase (pancreatitis), and U&Es (dehydration/renal function).
• Imaging: In GP, you might order a non-urgent Ultrasound (USS) for suspected gallstones or a CT for suspected cancer (via the 2-week wait pathway).

Safety Netting is the final, vital step. If you're sending a patient home, they need to know exactly what to look for (e.g., "If the pain moves to the right lower side or you start vomiting, you must go to A&E").

Does that help clarify the approach, or would you like to dive deeper into a specific differential, like appendicitis or diverticulitis?