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Republic of the Philippines

DEPARTMENT OF HEALTH
REGIONAL OFFICE NO. 1

ILOCOS TRAINING AND REGIONAL MEDICAL CENTER


City of San Fernando, La Union

Tel: (072) 607-6418/6422 Telefax: (072) 700-3719 itrmc_traniningoffice@yahoo.com


CERTIFIED ISO 9001:2008 September 2013

EVALUATION OF PATIENTS
PRESENTING WITH

ABDOMINAL PAIN

DEPARTMENT OF COMMUNITY
AND FAMILY MEDICINE

CLINICAL CLERKS:
PRABHURAMMURALIM GIRITHARAN
LABTANG, CHERRY FAITH M.
NARAYANASAMY, MADHUMITHA
TERAIYA, KULDIP
ABDOMINAL PAIN
Y
Evaluate HISTORY OF TRAUMA/RECENT SURGERY
Refer to surgery
N
*OB-Gyne history
MALE FEMALE *Consider
gynecologic causes

(-) (+)
1.General
appearance: Fetal *Evaluate
positioning, *Refer to OB-
Diaphoretic, Gyne
Erroneous VS,
2. Focused Physical Severe SEVERITY OF ABDOMINAL PAIN
exam
3. Peritoneal Signs Mild-Moderate
4. Refer accordingly 1. General appearance:
LOCALIZATION Fetal positioning,
Diaphoretic, Erroneous VS
2. R/O Extra abdominal
causes:Cardiac/ Pulmonary
causes: CXR, ECG
3. Co-Morbids
4. Signs of Abdominal Aortic
Aneurysm
5. Refer

RUQ EPIGASTRIC RLQ LLQ HYPOGASTRIC

COLIC HISTORY OF DIVERTICULAR


DISEASE OR WITH FEVER

HEPATOBILIARY CAUSES
ASSEESS FOR DISTENTION,
TENDERNESS, RECTAL FULL RECTAL
BLEEDING, DRE VAULT

1. MURPHY’S SIGN
2.CHARCOT’S TRIAD NEPHROLITHIASIS
3. REYNOLDS PENTAD
(-) (+) (-)
URINARY OR
(+) 1. UA, KUB UTZ GYNECOLOGIC PROBLEM
2.REFER ACCORDINGLY
HEPATOBILIARY CAUSES
1. WAUTZ CONSTIPATION
2. CT-SCAN DIVERTICULITIS
3. ENDOSCOPY
4.REFER ACCORDINGLY
FEVER WITH PAIN FROM Dx
PERIUMBILICAL AREA TO RLQ 1. UA,
Pregnancy Test
Y N 2. Vaginal
swab, GSCS,
3. Pap smear
Y
PERITONITIS/
APPENDICITIS PSOAS SIGN, REBOUND Refer
TENDERNNESS,
accordingly
GUARDING

(+) (-)
Rovsing sign, Obturator,
Psoas
URINE, COLON,
PELVIC
EXAMINATION
WHOLE ABDOMEN UTZ
CT

A. Herrera (et. al), 2018, IM Platinum 3rd ed, pp. 304-343


Cartwright&Hudson (2008), Evaluation of Acute Abdominal Pain in Adults
REFER TO SURGERY
AM Fam Physician, from www.aafp.org/afp/20028/0401/p971.html
th
Bickley (2017), Bate’ Physical Examiniation and History taking 12 edition, pp. 449-500
Jameson (et.al), 2018, Harrison’s Principles of Internal Medicine 20th ed, p. 81
LOCALIZATION

EPIGASTRIC HYPOGASTRIC

COLICKY GYNECOLOGIC
REFER TO FEMALE CAUSES
PT
Y N Y
N
REFER TO COLIC IN URINARY SYMPTOMS,
RUQ
(+) COSTOVERTEBRAL
TENDERNESS, FEVER

GASTRIC CAUSES:
A. PUD UTi:
B. GASTRITIS Cystitis/
C. ACID
Pyelonephritis
RELATED
PANCREATITIS

DX: URINALYSIS, KUB UTZ


1. CULLEN’S AND TURNER SIGN TX: ANTIBIOTICS, NSAIDS
2. HISTORY OF BINGE DRINKING
3. SEVERE PAIN UNRELIEVED BY PAIN PANCREATITIS
RELIEVERS (+)
(-)
a. Serum Amylase,
O: ONSET OF PAIN Lipase
P: CERTAIN FOOD: COFFEE, b. REFER
FATTY, SPICY FOODS IMMEDIATELY
Q: BURNING/ HEAVINESS
R: RADIATION: STERNAL
AREA, BACK
S: SEVERITY, N/V
T: BEFORE/DURING/AFTER
MEAL

GASTRIC CAUSE

DX: ENDOSCOPY, BARIUM


SWALLOW
TX: PPIs, H2 Blockers,
Antacids

A. Herrera (et. al), 2018, IM Platinum 3rd ed, pp. 304-343


Cartwright&Hudson (2008), Evaluation of Acute Abdominal Pain in Adults
AM Fam Physician, from www.aafp.org/afp/20028/0401/p971.html
Bickley (2017), Bate’ Physical Examiniation and History taking 12th edition, pp. 449-500
Jameson (et.al), 2018, Harrison’s Principles of Internal Medicine 20th ed, p. 81
EVALUATION OF ABDOMINAL PAIN
CHECKLIST RATIONALE
1. Questions to be asked in HPI: Rule out first life threatening causes of
a. Do you have any History of Trauma/ Recent Abdominal Surgery? abdominal pain, and causes that
b. Female of Reproductive age: MIDAS, LMP, Sexual Activity require immediate surgical approach
c. Pertinent positives/Negative: DOB, SOB, Fever, Tachypnea, History of to prevent morbidity and mortality.
Cough, Colds, Immunization Status
d. Red flags: Erroneous VS, Diaphoresis, Fetal positioning, Palpable
pulsation in abdomen, bruits
Alarm symptoms: recurrent vomiting, evidence of GI bleeding, Early
satiety, Weight loss, Anemia, Jaundice
e. From 1-10, 10 being the most painful, please rate your pain?
f. Can you point where the pain is? Location of pain guides initial
g. Please, describe the pain you’re experiencing? Does it come and go? Is it evaluation of abdominal pain.
a steady pain? Did it start from not so painful to very painful?
h. Do you feel the same pain in any other part of your body other than the
one you pointed?
i. What relieves/worsens the pain?
j. Aside from the pain, do you have any other symptoms felt? Associated signs and symptoms are
j.i RUQ: fever, lethargy, dizziness when getting up predictive of certain causes of pain in
j.ii Epigastric: Burning sensation, nausea, vomiting the abdomen and will help narrow
j.iii RLQ: Migration of pain, Fever, Anorexia, down the diagnosis.
j.iv LLQ: Rectal bleeding, distention, diarrhea, constipation
j.v Hypogastric: Dysuria, Hematuria, Urgency, Frequency, Fever, Back
pain
2. Relevant History:
a. Past Medical History: Aides in ruling out extraabdominal
-Did you have any previous surgeries? causes of abdominal pain such as
-Do you have Hypertension? Diabetes Mellitus? What medications do heart and pulmonary condition.
you take? Are you compliant to these medications?
b. Family History:
-History of Hypertension, DM, premature death, Aneurysms,
Malignancies
c. Personal and Social History Most common cause of pancreatitis
-Do you drink? Did you recently have a drinking spree? include: gallbladder stone, binge
- Do you smoke? drinking, hypertriglyceremia.
-Did you have a history of illicit drug use?
-24-hour dietary intake
-Any physical activities?
-Sexual practices.
d. Environmental History:
-Where do you get your drinking water?
-Ask about safe food and water practices.
-Are you somewhere near factories?
3. Physical Examination Special maneuvers are highly
a. Vital Signs: Note for fever, hypotension/hypertension, tachycardia, predictive of certain disease
bradycardia, tachypnea, include BMI occurrence.
b. General survey: Consciousness, diaphoresis, in distress, fetal
positioning/smiling, assess for orientation
c. Skin: Cyanosis, pallor, jaundice, presence of skin tags
d. HEENT: Check for icterus, pale conjunctiva, yellowish palate/mucosa,
alar flaring, neck vein engorgement,
e. Chest and lungs: Note for retractions, lagging, accessory muscle use,
symmetry of chest wall, check for breath sounds
f. Heart: Note for visible pulsations, heaves, thrills, Tachycardia,
abnormalities in rhythm
g. Abdomen
g.1 Check for contour, shape, color: Note any bruises, ecchymoses,
erythema, jaundice, visible pulsations. Indicate their location
g.2 Check for bowel sounds on all quadrants, note for bruits
A. Herrera (et. al), 2018, IM Platinum 3rd ed, pp. 304-343
Cartwright&Hudson (2008), Evaluation of Acute Abdominal Pain in Adults
AM Fam Physician, from www.aafp.org/afp/20028/0401/p971.html
Bickley (2017), Bate’ Physical Examiniation and History taking 12th edition, pp. 449-500
Jameson (et.al), 2018, Harrison’s Principles of Internal Medicine 20th ed, p. 81
g.3 Percussion: Lightly percuss on all quadrants, shifting dullness, Percuss
for Liver size
g.4 Palpate: Note for rigidity, Guarding, Light palpation, lastly palpating
the painful area, Deep palpation of spleen, kidneys, and abdominal aorta
g.5 Special maneuvers:
Check for Peritoneal signs: Guarding, rigidity, rebound tenderness,
percussion tenderness
Check for Charcot’s Triad & Reynolds pentad: RUQ pain, fever, jaundice
+ shock, altered sensorium
Murphy’s sign: RUQ pain with arrest in inspiration upon palpation of
RUQ.
Rovsing sign: Deeply press LLQ, note positive pain that radiates to RLQ
Psoas sign: Place hand on pt’s right knee and ask pt to raise thigh
against hand. Ask pt to turn to left side then extend the right leg at hip.
Obturator: Flex patient’s right thigh at hip, with knee bent, rotate leg
internally
h. Rectal: external hemorrhoids, blood masses, tenderness, DRE
i. Genitourinary: External lesions, blood, masses, tenderness, discharges
(foul smelling or not), Pelvic exam, speculum exam
4. Plans
a. Diagnostics:
ECG, Chest Radiograph, Troponin To rule out possible Pulmonary and
Cardiac causes of abdominal pain

Urinalysis with Pregnancy test To rule out Urinary and Gynecologic


causes

Serum Amylase, Lipase Elevated in Pancreatic inflammation

KUB Ultrasound To rule out Urinary causes of colic

Whole Abdominal Ultrasound Evaluates regions not accessible by


endoscopy: e.g pancreas, gallbladder,
Endoscopy retroperitoneal organs

Diagnostic Testing Best diagnostic to evaluate obstructive


causes of pain be it in Bile ducts, Small
Appropriate diagnostic testing varies based on the clinical situation.
intestine, and colon. Also assesses,
-CBC ulcerations in the mucosa

:if infection or blood loss is suspected. Evaluates regions not accessible by


endoscopy
-AMYLASE AND LIPASE MEASUREMENT Used for diagnosis of mass, fluid
collections, organ enlargement
:recommended because an elevated lipase level with a normal amylase
level is not likely to be caused by pancreatitis
Pain relief

- URINALYSIS Indicated for patients with higher risk


of complication
:in patients with hematuria, dysuria, or flank pain.

-IMAGINING STUDIES: Relief and healing of erosive


esophagitis
:Recommendations for initial imaging studies are based on the location of Most effective mode of therapy
abdominal pain.

:Ultrasonography is recommended when a patient presents with right


upper quadrant pain.
Relief and healing of erosive
A. Herrera (et. al), 2018, IM Platinum 3rd ed, pp. 304-343
Cartwright&Hudson (2008), Evaluation of Acute Abdominal Pain in Adults
AM Fam Physician, from www.aafp.org/afp/20028/0401/p971.html
Bickley (2017), Bate’ Physical Examiniation and History taking 12th edition, pp. 449-500
Jameson (et.al), 2018, Harrison’s Principles of Internal Medicine 20th ed, p. 81
esophagitis
Most effective mode of therapy
Recommended Imaging Studies Based on Location of
Abdominal Pain
LOCATION
IMAGING
OF PAIN Serves as barrier, enhances mucosal
defenses, speeds ulcer healing
Right upper Ultrasonography
quadrant14 Relief of Pain
Left upper CT To prevent affecting other organs such
quadrant as kidney. Most important
intervention in Pancreatitis
Right lower CT with IV contrast media
quadrant15
Left lower CT with oral and IV contrast media
quadrant16
Suprapubic Ultrasonography
Eliminate infectious cause of UTI

Pain Relief

For patients with


nephro/ureterolithiasis small enough
to be passed in the urine. If not advise
CT Scan surgical approach.

Correct infectious cause

b. Therapeutics: Indicated for torsion, Ectopic


Biliary Diseases pregnancies
NSAIDs

Surgery

Acid Related Disorder


PPIs

H2R-Antagonist

Antacids

PUD
PPIs

H2R-Antagonist

Antacids

Cytoprotective agents

Acute Pancreatitis
Analgesics
Fluid resuscitation

A. Herrera (et. al), 2018, IM Platinum 3rd ed, pp. 304-343


Cartwright&Hudson (2008), Evaluation of Acute Abdominal Pain in Adults
AM Fam Physician, from www.aafp.org/afp/20028/0401/p971.html
Bickley (2017), Bate’ Physical Examiniation and History taking 12th edition, pp. 449-500
Jameson (et.al), 2018, Harrison’s Principles of Internal Medicine 20th ed, p. 81
Appendicitis
Immediate referral to surgery

Urinary Tract Infection


Antibiotic

NSAIDs

Increase fluid intake

Gynecologic Causes
Infections: Antibiotics

Surgery

c. Monitoring
-Advise follow-up usually after 1 week or when there is progressively,
severe pain.
-For patients with infectious cause, advise follow-up after last dose of
prescribed antimicrobial agent.

d. Disposition
-Check for red flags/alarm signs: recognize need for admission or immediate
surgery.
-Send home patients and advise follow-up for those with stable VS, low-risk,
no known comorbidities patients.

ANNA LEE D. BANTASAN, MD


Supervising Resident

A. Herrera (et. al), 2018, IM Platinum 3rd ed, pp. 304-343


Cartwright&Hudson (2008), Evaluation of Acute Abdominal Pain in Adults
AM Fam Physician, from www.aafp.org/afp/20028/0401/p971.html
Bickley (2017), Bate’ Physical Examiniation and History taking 12th edition, pp. 449-500
Jameson (et.al), 2018, Harrison’s Principles of Internal Medicine 20th ed, p. 81

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