Question

Mrs. Ho was admitted to the ward C4 with right abdominal pain for investigation at 0800 this morning. Mrs. Ho is alert and orientated and Nurse Mary is going to perform physical assessment for her.

Apply the Analysis of Symptoms in exploring Mrs. Ho’s abdominal pain.

Answer 1

Before performing and analysing physical examination first step is to carefully collect history.

Analyse abdominal pain with particular emphasis on six features: onset, progression, migration, character, intensity, and localization.

Onset

1. Collect history regarding onset- sudden, rapid, or gradual onset

2. Ask for time of onset at a precise moment, usually stating exactly what activity was going on at the time the pain began.

3. Pain of sudden onset occurs within a second and are commonly associated with perforation of the gastrointestinal tract from a gastric or duodenal ulcer, a colonic diverticulum, or a foreign body. Other common causes include a ruptured ectopic pregnancy, mesenteric infarction, ruptured aortic aneurysm, and embolism of an abdominal vessel.

4. Rapid onset begins with a few seconds and steadily increases in severity over the next several minutes with cholecystitis, pancreatitis, intestinal obstruction, diverticulitis, appendicitis, ureteral stone, and penetrating gastric or duodenal ulcer.

5. Pain of gradual onset is pain that slowly becomes more severe only after a number of hours or even days have elapsed. The patient's memory as to the time of onset of the pain is vague; he or she can pinpoint only the day or possibly the week of onset. Pain of gradual onset is commonly associated with neoplasms, chronic inflammatory processes, and large bowel obstruction

Progression

Ask about progression of the pain over the interval from the time of onset until the patient seek medical attention, is it continuous or intermittent, has the pain abated, or has it increased, have there been intervals of total absence of the pain, or has the pain always been present, changing only in character?

Referral pain/ migration of pain

Pain that "shifts" from the original site of onset to another location in the abdomen is mostly associated with acute appendicitis where periumbilical or epigastric pain (visceral) that is present early in the course of the disease is replaced with right lower quadrant (somatic) pain later in the illness when the parietal peritoneum gets involved with the inflammatory process.

Pain produced by irritation of the parietal peritoneum by contents leaking from a perforated duodenal ulcer may begin in the epi gastric region and may migrate to the lower quadrants of the abdomen or pelvis depending on the pathway that the leaking material takes through the abdominal cavity.

Nature/ character of pain

Ask patient to describe the character, or what kind of pain. Since the patient's description of the pain must be purely subjective, clear communication is very essential to precisely identify nature of pain.

You can help patient in describing the pain by suggesting similarities or comparisons, such as hunger pain, burning pain, sticking pain, cutting, crushing, like wringing out of a washcloth (cramping).

Intensity

It is an individual matter of perception. It can also be verified by patients’ facial expressions, positioning, participation in activities and ability to sleep.

Localization

Ask the patient to indicate the site of the pain while lying down and any change if they notice with change in position to standing and prone position to be certain of the true location.

Referred Pain and Accompanying Symptoms

Three cerebrospinal nerves, the phrenic, obturator and genitofemoral can carry referred pain certain intra-abdominal conditions. Their irritation can cause pain to be referred at different locations.

Accompanying factors

They are important in making an accurate diagnosis. Among the most important are nausea, vomiting, abdominal distention, diarrhoea, constipation, obstipation, tarry stools, chills, fever, urinary frequency, haematuria, and jaundice.

Aggravating and relieving factors: Effect of positioning, drugs, diet, home remedies

Assess vital signs

Patient's general appearance and vital signs can help narrow the differential diagnosis. High temperature suggests infection; however, its absence does not rule it out, especially in patients who are older or immunocompromised.

Tachycardia and orthostatic hypotension suggest hypovolemia.

Procedure for physical examination

Preparation

· Wash your hands and warm them prior to examining the patient.

· Have the patient put on a gown. An extra drape is necessary to cover the lower body.

· Begin with the patient lying supine on the exam table or bed.

Approach to assess abdominal pain

Begin with a assessment of vital sign tests.

Inspection

· After entering the room, immediately begin careful inspection. Patients with peritonitis may prefer to lie still with flexed hips and knees.

· Place a drape over the patient's lower body to the pubic symphysis and raise the gown to just below the breasts.

· Note abdominal distension, skin colour, signs of poor perfusion, such as mottling, visible pulsation, or peristalsis, bulges, and scars.

· As the patient is alert, ask the patient to use one finger to point to the painful area.

· Ask the patient to cough (cough test) or gently bump the bed, which can localize the pain of peritonitis.

Auscultation

· Auscultate the left lower quadrant using the diaphragm with light pressure. Absent bowel sounds may indicate an ileus, while high pitch sounds suggest impending mechanical obstruction.

· Auscultation is least effective diagnostic technique for abdominal pain.

· Auscultate over any bulging areas to assess for herniated bowel.

· Proceed to use the head of the stethoscope to palpate the four quadrants with graduated pressure, while continuing to auscultate.

· Observe the patient's face for signs of distress, and feel the abdominal wall for rigidity.

Percussion

· Percuss the abdomen, beginning with very light percussion (light percussion test) over the four quadrants. This can localize peritoneal pain and distinguish it from visceral pain.

· Continue with a moderate percussion stroke in the four quadrants, assessing for abnormal tympany, suggesting air (free air or gas-filled bowel), or dullness, suggesting fluid or mass.

· Ask the patient to flex the legs at the hips and knees.

Palpation

· Begin palpation by placing the open right hand gently on the abdomen with fingers slightly spread.

· Use a light rocking motion as the patient breathes, feeling for abdominal wall rigidity.

· Feel each quadrant in this way, beginning farthest from the site of pain. Distracting the patient with conversation can serve to minimize voluntary guarding.

· Palpate again using moderate pressure with the finger pads (not the fingertips), in a clockwise fashion. In the middle of the clock face, palpate the aorta.

· Palpate bulges evoking suspicion of abdominal wall hernias, and attempt to reduce if present.

· In selected patients, particularly those with lower quadrant pain or suspicion of gastrointestinal bleed, perform a rectal examination.

Perform a testicular exam on males with lower abdominal pain.

Perform a pelvic and vaginal exam on females with abdominal pain.

Special Manoeuvres in Selected Patients with Abdominal Pain.

There are several specialized manoeuvres that evaluate for signs associated with causes of abdominal pain. When present, some signs are highly predictive of certain diseases

Test for Murphy's sign in patients with right upper quadrant pain. Palpate in the midclavicular line, just below the liver edge. Ask the patient to take a deep breath while you palpate deeply. Pain accompanied by cessation of inspiration suggests acute cholecystitis.

For right lower quadrant pain, the following manoeuvres can be diagnostically helpful:

Elicit Roving’s sign by deep palpation of the left lower quadrant. Pain referred to the right lower quadrant suggests acute appendicitis.

Perform the obturator sign by flexing the patient's right hip and knee to 90° and internally rotating the hip. Pain in the right lower quadrant suggests acute appendicitis or a pelvic abscess.

Perform the psoas sign by having the patient flex the right thigh against the examiner's resisting hand. Lower abdominal pain suggests a retrocecal appendicitis or psoas abscess.To perform an alternate method of the psoas sign, place the patient in the left lateral decubitus position, and standing behind the patient, extend the patient's thigh.

Perform the Carnet test to assess for abdominal wall pain, which can mimic intra-abdominal pathology and often goes undiagnosed. Identify the point of maximal pain in the supine patient, and palpate there with moderate pressure to elicit tenderness.

Ask the patient to raise the shoulders off the bed as if doing a sit-up, thereby contracting the abdominal wall muscles. Increased pain suggests an abdominal wall pain, while improved pain suggests intraperitoneal pathology (now protected by the contracted rectus muscles).

Assess for splenomegaly in patients with left upper quadrant pain or signs of portal hypertension.

Assess for ascites in patients with a suggestive history.

Assess for groin hernias: Symptomatic groin hernias may be present with groin pain, an unreducible bulge, or signs of intestinal obstruction, such as abdominal distension, pain, and vomiting. Assessment for groin hernias should be undertaken in selected patients with lower abdominal or groin complaints. Ask the patient to stand, as this is the preferred position to evaluate for groin hernias. It can also be performed in the supine position if the patient is unable to stand, though easily reducible hernias may be missed in this position. Ask the patient to turn the head to the side, and cough or simply bear down, and continue to observe for new bulging or increased size of an existing bulge.

The exam findings that are most useful for increasing the probability of disease include rigidity and percussion tenderness for general peritonitis; McBurney's point tenderness, positive Roving’s sign, and positive psoas sign for appendicitis; positive Murphy's sign and right upper quadrant tenderness for cholecystitis; visible peristalsis, abdominal distension, and high pitched-hyperactive bowel sounds for small bowel obstruction.

Appropriate diagnostic testing varies based on the clinical evaluation

· A complete blood count if infection or blood loss is suspected

· Liver chemistries are important in patients with right upper quadrant pain

· A urine pregnancy test should be performed in women of childbearing age who have abdominal pain to confirm pregnancy and forms a basis for confirmation of site of pregnancy and to decide about choice of imaging studies

· Ultrasonography

· CT Scan

Common causes of right sided abdominal pain are

Biliary	cholecystitis, cholelithiasis, cholangitis
Colonic	colitis, diverticulitis, peptic ulcer, appendicitis, colitis, IBD, IBS, intestinal obstruction, peritonitis
Hepatic	abscess, hepatitis, mass
Renal	nephrolithiasis, pyelonephritis
Gynaecologic	Ectopic pregnancy, fibroids, ovarian cyst, tumours, torsion, PID
Abdominal wall	herpes zoster, muscle strain, hernia
Cardio-Pulmonary	Coronary artery disease, pneumonia, embolus
Others	narcotic withdrawal, sickle cell crisis, porphyria, IBD, heavy metal poisoning