Abdominal Pain History o Type

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o o o PE o

Visceral pain dull, aching, poorly localized; due to distention or spasm of hollow organ, i.e. early pain in intestinal discomfort or cholecystitis Parietal pain sharp, well localized; due to peritoneal irritation, i.e. pain of acute appendicitis w/spread of inflammation to parietal peritoneum Referred pain aching, seen as near surface of body Location Acute cholecystitis or hepatitis RUQ Appendicitis periumbilical area, RLQ Diverticulitis lower abd pain in midline, LLQ Esophagitis, PUD substernal pain in upper abd Pancreatitis radiates to back Renal colic radiates to groin Onset, frequency, duration Pancreatitis gradual, steady Rupture of a viscus w/resultant peritonitis sudden & max from start Quality Burning or gnawing GERD, PUD Colicky gastroenteritis, intestinal obstruction Severity Factors that aggravate or alleviate Mesenteric ischemia pain starts w/in 1 hr of eating PUD pain is relieved by eating, recurs several hrs after meal when stomach is empty Pancreatitis pain is relieved by sitting up & leaning forward Peritonitis pts lie motionless on back b/c any motion causes pain Also note if pain occurs in conjunction w/lactose or gluten-containing foods lactose intolerance or celiac disease Other sx Malignancy weight loss Bowel obstruction N/V Colonic lesion change in bowel habits Make sure women are asked about their sexual history in case of STI Ask all premenopausal women about their menstrual hx Dont forget to R/O pregnancy in all women of childbearing age General Look at position of pt when in pain immobility is typical of peritonitis, pts w/biliary or renal colic writhe in agony

Vitals measure orthostatic changes in BP & HR Obstruction, peritonitis & bowel infarct can cause lots of third spacing of fluid & intravascular volume depletion or overt shock Eyes look for scleral icterus Skin look for jaundice Lungs look for consolidation Heart murmurs, rubs Abdomen Auscultation Abnormal bowel sounds small bowel obstruction No bowel sounds advanced peritonitis, dynamic ileus Abnormally active high-pitched bowel sounds early bowel obstruction Friction rub in appropriate area splenic infarct or hepatic metastasis Percussion can ID ascites, liver span, bladder & splenic enlargement, good for acute peritonitis, can test for rebound tenderness Tympany distended bowel Dullness mass Shifting dullness ascites Palpation Muscular rigidity or guarding early sign of peritoneal inflammation (unilateral in focal inflammatory mass or diffuse in peritonitis) Guarding is absent w/deeper sources of pain (renal colic, pancreatitis) Can also be used to detect enlarged organs or masses Rectal & pelvic Fecal impaction could explain signs of obstruction in elderly Tenderness on rectal exam might be only abnormal finding for pt w/retrocecal appendicitis Get FOBT Pelvic exam tells if abd pain is due to PID, adnexal mass or cyst, uterine pathology or ectopic pregnancy Other examine for signs of nerve & muscle wall injury & hernia Pain in dermatomal distribution & hyperesthesia signs of nerve involvement (herpes zoster, nerve root impingement) Abd wall pathology can be found by palpation or noting exacerbation of pain when using abd wall mm, i.e. sitting up