Assessment Skills: Abdominal Pain (painiac Essential Guide)

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Assessment Skills: Abdominal Pain (painiac Essential Guide)

Post by painiac » Sat Apr 23, 2016 12:19 pm

painiac's Essential Guide to Physical Assessment Skills: Part 1, Abdominal Pain

Abdominal pain is one of the most common, potentially serious problems we see in the Emergency Room. I decided to put together a guide for approaching this complex problem. Depending on interest and response, I will probably write up some more assessment guides as time permits.

We would be very limited in our ability to diagnose without labs (particularly: complete blood count, amylase, lipase, liver function, urinalysis) and imaging (abdominal xray is helpful, CT scan is better). That being said, knowing how to perform a physical examination of the abdomen is very important even if labs and imaging were to be unavailable. Your assessment combined with the history and presentation all give valuable clues to a diagnosis that is sometimes only confirmed by imaging and labs. All you need for an abdominal assessment are a stethescope, your senses, and the knowledge of what questions to ask and how to evaluate the answers.

Underlying Anatomy
Understanding of the underlying anatomy is obviously critical. For assessment purposes, the abdomen is divided into quadrants, named from the perspective of the patient's right/left (not yours). This is just a quick and dirty listing off the top of my head. Refer to anatomy drawings.

Left Upper Quadrant (LUQ) - stomach, some of the small intestine, part of the transverse portion and part of the descending portion of the large intestine, pancreas (farther to the left of which is the spleen)

Left Lower Quadrant (LLQ) - distal descending portion of the intestine, part of the small intestine

Right Upper Quadrant (RUQ) - liver, gallbladder, part of the ascending portion and part of the transverse portion of the large intestine, part of the small intestine

Right Lower Quadrant (RLQ) - part of the small intestine, part of the ascending portion of the large intestine, appendix

The abdominal organs are separated from the thoracic organs (heart and lungs) by the diaphragm, through which the esophagus passes.

The bladder lies in the center, down in the pelvis. A full bladder can be felt. In women, the uterus lies behind and slightly above the bladder, and the ovaries lie to either side.

The kidneys are in the lower back on either side of the spine (flanks)

Near the midline lies major blood vessels, particularly the abdominal aorta. With skinny patients, you can often see the vessel pulsing.

Sequence of Assessment
Inspection: First, look at the abdomen. Observe the overall shape: is it flat, or distended? If distended, is it symmetrical? Look for any obvious signs of trauma, such as lacerations, seatbelt abrasions, and bruises (in whatever stage of healing, progressing as they heal from red/purple to yellow). You are also looking for any lumps or protrusions such as a hernia. A hernia is fluid or even a section of intestine that is sticking out between weakened areas of muscles of the abdomen. Hernias will usually bulge outwards when the patient bears down; they are usually benign, but they can become "incarcerated" or "strangulated" (where bloodflow is cut off). Look for any scars that indicate previous surgeries, as the surgical history can handily rule out possibilities (if the appendix or gallbladder have been removed, they can't be the source of the current problem).

Auscultation: Listening to the bowel sounds with a stethescope is known as auscultation. You need to do this BEFORE you palpate the abdomen, because pressing on the bowels will alter the bowel sounds. More on bowel sounds in the next section.

Percussion: is a technique where you lay a finger across different areas of the abdomen and then sharpy tap it with a finger of your opposite hand. With practice, you can hear the difference in the sound made based on the density of the underlying organs. Hollow organs make a drum-like sound called tympany. Dense organs like the liver make a dull thud. If the abdomen is filled with fluid, either localized (as in a hematoma) or generalized (as in ascites), the sound will be dull. Placing your hand flat on each flank and then lightly hammering it with your fist will elicit pain if the kidneys are inflamed (as from infection or kidney stone).

Palpation: When palpated (pressed), you are feeling whether the abdomen is soft or firm, whether there are any lumps or protrusions where there shouldn't be, whether any of the organs are larger or harder than they should be, and whether the patient clenches up their abdominal muscles or tries to block your hands or withdraw from your touch (guarding). Areas can be tender or nontender (meaning that pressing on it does not elicit pain, or does not elicit any additional pain). Rebound tenderness may be present, meaning pressing in is not very painful but the patient experiences pain when you release the pressure: rebound tenderness is characteristic of peritonitis, and is a late classic sign of appendicitis.

Bowel Sounds
A gurgle is normal. A high-pitched gurgle can signal a narrowing or a partial obstruction of the bowel.

Normal bowel sounds are a fairly frequent gurgling throughout all four quadrants, at least one gurgle about every 3-5 seconds.

HYPERactive (fast) bowel sounds occur once every second or so. You'll have this when things are being moved through quickly, i.e. diarrhea

HYPOactive (slow) bowel sounds occur maybe up to or beyond 10 seconds apart

Absent bowel sounds are very infrequent or even completely absent. This occurs if the bowel is paralyzed (usually temporarily, as in an ileus). If the bowel is completely obstructed, bowel sounds will typically be relatively normal or hypoactive up to the abstruction, and absent distal to the obstruction.

Characterization of Pain
Rating: Pain is rated on a scale of 1 (almost no pain) to 10 (the worst pain imaginable). This scale is highly subjective. Smartass patients frequently try to rate their pain as being off the possible scale, like "11". As in, "Twelve out of ten healthcare professionals annoyed by patients' misuse of pain scale".

A kidney stone or a twisted bowel can easily be a legit 10. Pain tolerance obviously varies. Some people will report a 9 or 10 to discomfort that you might rate as a 3 or 4, and many of these people will preface this by claiming that they "normally have a very high pain tolerance". Stoics will vastly under-report their pain, as will those little old ladies who "just don't want to be a bother". Getting the patient to quantify their pain is more about establishing a baseline, against which you can measure the effectiveness of medications.

Character: Pain is characterized as sharp, dull, aching, cramping, burning, or pressure.

Duration: When did the pain start? Pain is either constant or intermittent.

Mitigating/Exacerbating Factors: Pain may be relieved, exacerbated, or unaffected by various factors such as eating, movement, or applying pressure.

Location: Pain in the abdomen is localized in several ways: in one or more quadrants, epigastrically (over the stomach), suprapubically (over the bladder), in the flank (to the right or left of midline in the back), or generalized (across the entire abdomen).

Pain can also travel or migrate: pain which changes locations is most characteristic of a kidney stone that has moved. Kidney stones and a kidney infection (pyelonephritis) can both present as pain which feels like it begins in the flank and wraps around to a lower quadrant or the groin. Pain from some organs may actually be referred elsewhere, such as to the shoulder.

Complaint, Presentation, and History
Presentation: gives a great deal of information. Is the patient calm, or distressed? Are they moaning and/or grimacing? Conversing normally, or reluctant to speak? A helpful generalization is that a patient with appendicitis is reluctant to move (because any movement aggravates peritonitis), and a patient with a kidney stone can't stop moving (we call this the "kidney stone dance" or "kidney stone shuffle").

History: Key information is gleaned from the patient's history.
Any nausea/vomiting? How frequent? After vomiting, people will experience epigastric soreness or cramping pain: this seems obvious, but a LOT of people seem to think this is significant enough to seek emergency room evaluation. It isn't.
Any blood in the vomit? Blood that is very fresh will be dark or light red. Blood that is partially digested looks like coffee grounds.

When was the patient's last bowel movement, and was it a normal consistency for them? Most people will have a bowel movement every 1-3 days. Constipation can cause a lot of abdominal discomfort.
Treatment escalates from stool softeners to mild laxatives to non-mild laxatives. In extreme cases of chronic constipation, there might be an impaction of stool in the rectum that you must manually remove by inserting your finger, making a hook, and pulling the stool out. Manually disempacting a patient makes you seriously question the path you've chosen in life.

Any diarrhea? How frequent?

Any obvious blood in the stool? Bleeding in the distal colon will be light or dark red. Blood that has passed through the digestive tract will make the stool more-or-less uniformly dark red or black. Stool from a GI bleed has a strong, distinct odor that you will not forget.

Diarrhea caused by ulcerative colitis may have a little mucus in it. Diarrhea caused by Clostridium difficile is usually a light brown with a lot of mucous in it, and has its own distinct odor.

Irritation to the gastrointestinal tract (gastritis or gastroenteritis) that results in vomiting and/or diarrhea is usually self-limited, but can progress to dehydration and life-threatening electrolyte imbalance if not managed.

When did the patient last urinate? Any difficulty starting their urine stream? This signals an obstruction, which could be swelling, an enlarged prostate, or it could be a kidney stone causing a blockage.

Do they experience any burning or pain with urination? Any sense of urgency? Are they urinating more frequently than normal? This irritation could signal a urinary tract infection, or an STD.

Do they describe a foul smell to their urine? This can arise from an infection. Some people with a particular genetic mutation will get foul-smelling urine when they eat asparagus: this mutation occurs at the MTFHR gene, called the "motherfucker" gene by some researchers.

Does their urine have an unusual color? Depending on hydration status, normal urine will vary from almost clear, to pale yellow, all the way to a medium or somewhat dark yellow.
Some medications, supplements, and food dyes can harmlessly discolor the urine: anything from orange, green, blue, etc.
Urine that's dark yellow can indicate dehydration or kidney insufficiency, particularly if the amount of urine is smaller than usual.
A small amount of blood in the urine from a kidney stone or a bad urinary tract infection will make the urine darker than normal.
A large amount of blood will obviously be more visible: the urine will be either pink-tinged, dark red like fruit punch, or opaque blood. This much bleeding typically occurs from a tumor, after a surgical procedure to the prostate, or from a traumatic foley catheter insertion or removal (such as the patient yanking theirs out).
Urine that is dark brown (tea-colored) shows a large excess of bilirubin in the urine, which can arise from liver failure or from trauma (especially crush injuries) -- this can actually clog up the kidneys, part a dangerous condition known as rhabdomyolysis.

Has the patient sustained any trauma? A motor vehicle crash can impart trauma to the abdomen that is significant enough to lacerate solid organs like the liver or spleen, and rupture hollow organs like the bowels or bladder. A significant deceleration with a seatbelt across the abdomen can do a lot of damage, and bruising/abrasions on the skin from the seatbelt will usually give evidence of this. A motor vehicle crash can be the first thing that comes to mind, but also don't discount falls or being struck.

Does the patient drink a lot of alcohol? Alcoholism has several notable long-term effects. Probably the most common complaint we see resulting from alcoholism is pancreatitis, an extremely painful condition where the pancreas essentially is in the beginning stages of digesting itself. Pancreatitis pain is typically the LUQ, but may stretch across to the RUQ or even be generalized. Continuing to drink alcohol after suffering a bout of pancreatitis will often cause it to flare back up.
All of the blood in the body passes through the "portal vein" of the liver. When a liver is significantly damaged, its ability to filter the blood is diminished, and fluid will back up in the system. This results in a significant amount of fluid accumulating in the abdominal cavity (ascites). Blood also backs up in the blood vessels of the esophagus, resulting in varicose vessels there that can rupture (often fatally). A late sign of chronic liver damage is jaundice (a yellowing of the eyes and skin that results from a buildup of bilirubin that is normally broken down by a healthy liver. The liver can be enlarged, which you can feel in the RUQ.

Liver damage can also occur from a drug overdose, chiefly acetaminophen (Tylenol). If they're showing signs of liver failure from acetaminophen overdose, it's already too late.

Does their pain occur after eating? This points to the gallbladder, which will usually present as RUQ pain that is accompanied by nausea.
Is their pain instead relieved by eating? This may indicate a stomach ulcer.

Ovarian cysts can become extremely painful, but usually the pain disappears if they rupture. They often present as nausea/vomiting, bloating, and pain during bowel movements and/or during sex.

Appendicitis warrants special mention. The classic signs are RLQ pain (or pain elsewhere in the abdomen that later localizes to the RLQ), fever and chills, and rebound tenderness. This does not mean appendicitis will only present this way, merely that these are the classic signs. Appendicitis is a surgical emergency and requires IV antibiotics.

Patients with an abdominal aortic aneurism (AAA) that is dissecting will describe a severe pain that feels like something is tearing. These patients will become unstable very quickly as their blood flow is compromised. If it ruptures, their entire blood supply dumps into their abdominal cavity. Immediate surgical intervention is their only small chance of survival.
Last edited by painiac on Sun Apr 24, 2016 3:27 pm, edited 6 times in total.

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Re: Assessment Skills: Abdominal Pain (painiac Essential Gui

Post by dallas » Sat Apr 23, 2016 12:37 pm

Very good primary. You could add a differential list.

Right upper quadrant

Biliary: cholecystitis, cholelithiasis, cholangitis
Colonic: colitis, diverticulitis
Hepatic: abscess, hepatitis, mass
Pulmonary: pneumonia, embolus
Renal: nephrolithiasis, pyelonephritis


Biliary: cholecystitis, cholelithiasis, cholangitis
Cardiac: myocardial infarction, pericarditis
Gastric: esophagitis, gastritis, peptic ulcer
Pancreatic: mass, pancreatitis
Vascular: aortic dissection, mesenteric ischemia

Left upper quadrant

Cardiac: angina, myocardial infarction, pericarditis
Gastric: esophagitis, gastritis, peptic ulcer
Pancreatic: mass, pancreatitis
Renal: nephrolithiasis, pyelonephritis
Vascular: aortic dissection, mesenteric ischemia


Colonic: early appendicitis
Gastric: esophagitis, gastritis, peptic ulcer, small-bowel mass or obstruction
Vascular: aortic dissection, mesenteric ischemia

Right lower quadrant

Colonic: appendicitis, colitis, diverticulitis, IBD, IBS
Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID
Renal: nephrolithiasis, pyelonephritis


Colonic: appendicitis, colitis, diverticulitis, IBD, IBS
Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID
Renal: cystitis, nephrolithiasis, pyelonephritis

Left lower quadrant

Colonic: colitis, diverticulitis, IBD, IBS
Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID
Renal: nephrolithiasis, pyelonephritis

Any location

Abdominal wall: herpes zoster, muscle strain, hernia
Other: bowel obstruction, mesenteric ischemia, peritonitis, narcotic withdrawal, sickle cell crisis, porphyria, IBD, heavy metal poisoning

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Re: Assessment Skills: Abdominal Pain (painiac Essential Gui

Post by zXzGrifterzXz » Mon Apr 25, 2016 10:41 am

Thank you painiac, that is a good quality write-up with a lot of great info. Also thanks to dallas, for the differential diagnosis list. Its always good to keep other possible causes in mind and not focus on your first initial impression as you run the risk of ignoring other possibilities.

Only thing I can think to add is if the Pt states their pain is localized to the specific area of the abdomen, always make sure to start palpation on the opposite side of the abdomen as far from the existing pain as possible. If you start palpation on the effected quadrant, it is possible that your palpation can cause radiating pain to other quadrants and you run the possibility of being left with a Pt that gives you answers like "my whole stomach hurts" or "everything hurts" thus muddying your findings.
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Re: Assessment Skills: Abdominal Pain (painiac Essential Gui

Post by phil_in_cs » Mon Apr 25, 2016 2:05 pm

painiac wrote: Characterization of Pain
Rating: Pain is rated on a scale of 1 (almost no pain) to 10 (the worst pain imaginable). This scale is highly subjective. Smartass patients frequently try to rate their pain as being off the possible scale, like "11". As in, "Twelve out of ten healthcare professionals annoyed by patients' misuse of pain scale".
I had appendicitis 2 summers ago. Mostly felt constipated, and up high - almost at the lower edge of my ribs. No pain at all until HOLY MOTHER OF GOD IT HURTS. When I got to the ER, the doc gave me some morphine. 5 minutes later he asked if it still hurt. "OH GOD YES" so he gave another slug of morphine. 5 minutes later he asked if it hurt. It did, just as bad, so he gave me some dilaudid. 5 minutes and he asks and my reply was "huh? yeah, I guess, but don't worry about it. I'm fiiiiine..."

Since it hadn't hurt and I hadn't had a fever, I waited too long to get to the ER. It didn't rupture, but it fused to my lower bowel and I ended up with a 5 hour surgery and lost half a foot of my guts. I realized about a month later I came closer to dying from that than I did from the heart attack the previous year. At least the heart attack had given me a reference point for the pain, though I've talked to others that felt very little pain from their heart attack and had much more damage than I did.
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Re: Assessment Skills: Abdominal Pain (painiac Essential Gui

Post by doitnstyle1 » Mon Apr 25, 2016 10:57 pm

Awesome information! Thanks. There was stuff there that I did not know or just plain forgot.

I would like to add:

Rovsing's sign, named after the Danish surgeon Niels Thorkild Rovsing (1862 -1927),[1] is a sign of appendicitis. If palpation of the left lower quadrant of a person's abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis.

In acute appendicitis, palpation in the left iliac fossa may produce pain in the right iliac fossa.

Referral of pain
This anomaly occurs because the pain nerves deep in the intestines do not localize well to an exact spot on the abdominal wall, unlike pain nerves in muscles. Pain from a stomach ulcer or gallstone can be interpreted by the brain as pain from the stomach, liver, gall bladder, duodenum, or first part of the small intestine. It will "refer" pain often to the mid upper abdomen.

Because the appendix is a piece of intestine, it follows a similar referral pattern. An appendix with some early inflammation may give a non-specific irritation somewhere near the umbilicus (belly button). Should the inflammation become severe, it may actually irritate the inner lining of the abdominal cavity called the peritoneum. This thin layer lies under or behind the abdominal wall muscles. Now the pain is "localized". If pressure is applied to the muscles of the right lower abdomen (or iliac fossa) near a very irritated appendix, then the muscle fibers in that area will be stretched and will hurt.


Psoas sign

The psoas sign, also known as Cope's psoas test or Obraztsova's sign, is a medical sign that indicates irritation to the iliopsoas group of hip flexors in the abdomen, and consequently indicates that the inflamed appendix is retrocaecal in orientation (as the iliopsoas muscle is retroperitoneal). It is elicited by performing the psoas test by passively extending the thigh of a patient lying on his side with knees extended, or asking the patient to actively flex his thigh at the hip.[3] If abdominal pain results, it is a "positive psoas sign". The pain results because the psoas borders the peritoneal cavity, so stretching (by hyperextension at the hip) or contraction (by flexion of the hip) of the muscles causes friction against nearby inflamed tissues. In particular, the right iliopsoas muscle lies under the appendix when the patient is supine, so a positive psoas sign on the right may suggest appendicitis. A positive psoas sign may also be present in a patient with a psoas abscess. It may also be positive with other sources of retroperitoneal irritation, e.g. as caused by hemorrhage of an iliac vessel.


Markle sign

The Markle sign or jar tenderness is a clinical sign in which pain in the right lower quadrant of the abdomen is elicited by dropping from standing on the toes to the heels with a jarring landing. It is found in patients with localised peritonitis due to acute appendicitis.[1] It is similar to rebound tenderness, but may be easier to elicit when the patient has firm abdominal wall muscles. Abdominal pain on walking or running is an equivalent sign.

These were the three I remember to check in the field before evacuating.
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Re: Assessment Skills: Abdominal Pain (painiac Essential Gui

Post by doitnstyle1 » Mon Apr 25, 2016 11:03 pm


Info added to my files.

Please keep them coming.
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