Assessing Abdominal Pain
This discussion is divided into two parts:
Make a thorough list of pertinent information to collect when assessing abdominal pain.
How do you evaluate abdominal masses and how do you document such findings?
Describe your findings on a previous patient who had a mass in the abdomen that you had palpated.
Define, compare, and contrast the conditions listed below:
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Assessing Abdominal Pain
The causes of abdominal pain can range from minor (mild constipation) to potentially fatal (abdominal aortic aneurysm or acute MI). Because so many diseases can cause abdominal pain, the key to establishing a differential diagnosis in such cases is a thorough history and physical exam. Both of these are skills that providers of any level can perform, though becoming and maintaining proficiency takes practice.
RECORDING THE PATIENT’S HISTORY
Dr. Lisa Sanders discusses the idea that patients spend a significant amount of time crafting the narrative of their illness and the events leading up to the onset of their symptoms in her book “Every Patient Tells a Story” . Sanders believes that asking a question while taking a patient’s history and actually listening to the answer has value. Sanders, who is on the faculty of Yale Medical School, was a technical advisor for the TV show “House, M.D.” and is an experienced diagnostician.
ARTICLES RELATED TO
Abdominal pain evaluation
Examine the patient’s complaints for any associated symptoms or negatives.
How to Use the OPQRST as a Patient Assessment Tool
FEATURE RELATED TO
Scenario clinical: Female with stomach pain
All too often, medical providers will ask a question of a patient and then move on to the next question. If you take a moment to listen, the patient will tell you what’s wrong.
After determining the location of the pain, ask the patient about the severity and quality of the pain. Is the location changing? Has the pain become more severe? Make use of the OPQRST questions.
The history of the event is especially important in cases of abdominal pain. Aside from simply understanding what the patient was doing when the pain started, try to determine if there is anything that makes the pain worse or better. Pain can be positional, occur after eating, or occur immediately upon waking in the morning. Each of these pain-related questions allows you to narrow down the list of possible diagnoses.
In the case of abdominal pain, be sure to inquire about bowel and urinary habits. Understanding when a patient’s body is not acting in accordance with what is “normal” (for him or her) can provide clues about a potential disease .
It is also necessary to obtain information about a female patient’s sexual and menstrual history. A presenting symptom of abdominal pain in patients who may be pregnant should generate a “must not miss” diagnosis of ruptured ectopic pregnancy, a potentially life-threatening condition. Ask these questions in a setting that respects the patient’s privacy. Minor patients have a protected right in many states to access “sensitive services,” which are those related to sexual and reproductive health. Make sure you understand and follow the laws in your area.
A DETAILED PHYSICAL EXAMINATION
When preparing to perform a physical exam on a patient who is complaining of abdominal pain, you should first pinpoint the source of the discomfort. After obtaining a history of the patient’s complaint, examine the abdomen for swelling or bruising. If the patient’s physical appearance differs from normal, a family member or caregiver can often inform you (i.e. acute swelling of the abdomen rather than chronic obesity). When palpating the abdomen, start in the quadrant farthest away from the area of complaint and continue to speak with the patient. This can distract the patient and allow you to determine how much pain is radiating and how severe it is . Because conditions such as heart attack and pneumonia can cause abdominal pain, it is critical to rule these out as well.
During the physical exam, you must be able to see and feel the patient’s skin. Look for surgical scars and, if you find them, inquire about the procedure that caused the scar.
CONSTRUCTING A DIFFERENTIAL DIAGNOSIS
In addition to determining a working diagnosis, it is critical to include several serious “must not miss” diagnoses in abdominal pain patients. Myocardial infarction should be considered as a possible cause of pain in the epigastric (upper abdominal) region. When pain occurs in the right or left lower quadrants of sexually active women of child-bearing age, a possible diagnosis of ectopic pregnancy should be considered. In such cases, a menstrual history can help rule out the possibility of an ectopic pregnancy .
While most common in patients aged 10 to 19, appendicitis has become more common in patients aged 30 to 69 . Observable findings for acute appendicitis as your working diagnosis include :
The pain is near McBurney’s Point, which is about halfway between the top of the hip and the umbilicus.
Pain gradually migrates to the right side of the abdomen
Absence of vaginal bleeding
Guarding is the tensing of abdominal muscles in response to palpation.
After taking Lori’s history and performing a physical examination, you determine that, while she most likely has appendicitis, there is still a possibility that she is suffering from a ruptured ectopic pregnancy. Because her vital signs remain stable, you assist her into a comfortable position on the stretcher and transport her non-emergent to the nearest hospital. Lori’s CT scan revealed appendicitis, and she was taken to surgery on another return trip to the same facility. She is expected to recover completely and be discharged the following morning.