The causes of abdominal pain can range from simple (mild constipation) to life-threatening (abdominal aortic aneurysm or acute MI). Because so many diseases can present with abdominal pain, the key to building a differential diagnosis in such cases is performing a detailed history and physical exam. These are skills that providers of any level can perform, though it takes practice to become and maintain proficiency.
Patient with abdominal pain
“Medic 109, I show you responding Code 2 to 723 West Elm for a report of a 34-year-old female with abdominal pain.”
When you reach the front door you are met by a woman, Lori, who identifies herself as the 911 caller. As she points to her right lower quadrant, Lori explains that she has been experiencing abdominal pain that has been worsening throughout the day. She also says she feels slightly nauseous, but has not thrown up. She reports feeling weak and you assist her to a chair by the front door.
Patient assessment findings
While your partner takes vital signs, you begin to ask Lori more questions. She says she has never experienced pain like this before and that she awoke with the pain this morning. She estimates that the pain began as two out of 10 and has steadily increased to five out of 10.
When you palpate the area where the pain is most severe Lori gasps and you feel the muscles of her abdomen tense up. She once again denies vomiting and reports normal urination and bowel movements. Lori had a normal menstrual period last month and is due to begin again in “a few days.” She also denies any vaginal bleeding. Lori has a history of pre-hypertension and has been told to make dietary improvements by her physician, but is not on any medications. Lori’s vital signs are: BP 148/98, HR 126, RR 16, SpO2 97%.
- What are several potential differential diagnoses?
- What is a “must not miss” diagnosis?
- What are your first steps for treatment?
Taking a patient history
In her book “Every Patient Tells a Story,” 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 their symptom onset [1]. Sanders states that there is value in asking a question while taking a patient’s history and actually listening to the answer. In addition to being on faculty at the Yale Medical School, Sanders was a technical advisor for the TV show “House, M.D.” and is an experienced diagnostician.
All too often, medical providers ask something of the patient and immediately start thinking about the next question. If you stop and listen, the patient will tell you what is wrong.
After understanding where the pain is located, begin by asking the patient about the quality of the pain and its severity. Has the location moved? Has the pain increased in severity? Use the OPQRST questions.
In cases of abdominal pain, the history of the event is especially valuable. In addition to simply understanding what the patient was doing when the pain began, also try to determine if there is anything that makes the pain better or worse. Sometimes pain is positional or can occur after eating or immediately upon waking in the morning. Each of these questions about the pain allows you to narrow down the list of potential diagnoses.
For abdominal pain, be sure to ask about bowel and urinary habits. Understanding when a patient’s body is not acting in a way that is consistent with what is “normal” (for him or her) can provide clues about a possible disease [2].
For female patients of child-bearing age, it is also important to obtain specifics of her sexual and menstrual history. In patients who might be pregnant a presenting symptom of abdominal pain should generate a “must not miss” diagnosis of ruptured ectopic pregnancy which is a potentially life-threatening condition. Be sure to ask these questions in an environment that respects the patient’s privacy. In many states, even minor patients have a protected right to access “sensitive services” which are those related to sexual and reproductive health. Be sure to understand and follow your local laws.
Performing a detailed physical exam
When preparing to perform a physical exam on a patient complaining of abdominal pain, you should first determine the location of the pain. After taking a history of the complaint from the patient, then inspect the abdomen looking for swelling or bruising. Often the patient, a family member or a caregiver can inform you if the patient’s physical presentation is different from normal (i.e. acute swelling of the abdomen rather than chronic obesity). When palpating the abdomen, begin in the quadrant furthest from the area the patient is complaining about and continue to speak with the patient. Doing so can distract the patient and allow you to determine how much the pain radiates and how severe it actually is [2]. Since conditions like heart attack and pneumonia present with symptoms that include abdominal pain it is important to rule out these diagnoses as well.
During the physical exam you need to see and feel the patient’s actual skin. Look for surgical scars and if present ask about the procedure that caused the scar.
Building a differential diagnosis
In addition to determining a working diagnosis it is important in abdominal pain patients to include several serious “must not miss” diagnoses. When pain presents in the epigastric (upper abdominal) region, myocardial infarction should be considered as a possible cause. In sexually active women of child-bearing age a possible diagnosis of ectopic pregnancy should be considered when pain presents in the right or left lower quadrants. In such cases, menstrual history can be valuable in ruling out the concern for an ectopic pregnancy [2].
While most prevalent in patients age 10-19, appendicitis has become increasingly common in patients between the ages of 30 and 69 [3]. Findings of interest for acute appendicitis as your working diagnosis include [2]:
- The location of the pain near McBurney’s Point which is roughly half way between the top of the hip and the umbilicus
- Migration of the pain gradually to the right of the abdomen
- Lack of vaginal bleeding
- Guarding, which is tensing of abdominal muscles to palpation
Abdominal pain treatment
After obtaining a history and performing a physical examination, you determine that while Lori likely has an appendicitis, there is still a concern that she may be experiencing a ruptured ectopic pregnancy. Since her vital signs remain stable, you assist her into a position of comfort on the stretcher and transport non-emergent to the local hospital. On another return trip to the same facility you hear that Lori’s CT scan showed appendicitis and that she was taken to surgery. She is expected to fully recover and be discharged the follow morning.
References
[1] Sanders, L. (2009). Every patient tells a story: Medical mysteries and the art of diagnosis. New York, NY: Broadway Books.
[2] Stern, S. D., Cifu, A. S., & Altkorn, D. (2006). Abdominal pain. In Symptom to diagnosis: An evidence-based guide(pp. 9-31). New York: Lange Medical Books.
[3] Buckius, M., McGrath, B., Monk, J., Grim, R., Bell, T., & Ahuja, V. (2012). Changing epidemiology of acute appendicitis in the United States: Study period 1993-2008. The Journal of Surgical Research, 175(2), 185-190.
This article, originally published on February 17, 2015, has been updated.
