The Physical Examination

As with the history, the abdominal examination in the older patient proceeds in the same manner as for younger patients. Complicating factors may include the patient's stoicism or inability to report pain and the less pronounced muscular response to inflammation. 78 The following should be addressed:

• General Appearance: An ill-appearing older patient with abdominal pain should cause immediate concern, given the high mortality rate in general case series of elderly patients with abdominal pain.16 On the other hand, the clinician can be misled by a deceptively "well" appearance in the face of serious underlying disease.8

• Vital Signs: Reflexively think of a ruptured abdominal aortic aneurysm in the hypotensive older patient with abdominal pain. 11 Determination of a core temperature is advisable; however, lack of fever commonly occurs with serious infectious causes of abdominal pain. Tachypnea and tachycardia are nonspecific findings but should raise the possibility of a cardiopulmonary disorder.

• Inspection and Auscultation: Distention is common in large bowel obstruction, including sigmoid and cecal volvulus.12 High-pitched "rushes" suggest small bowel obstruction.

• Abdominal Palpation: In general, the location of tenderness is generally reliable in the older patient. Appendicitis usually manifests right-lower-quadrant tenderness,6,9,,13 while cholecystitis and pancreatitis generally cause tenderness in the expected location. 8 Unfortunately, abdominal guarding or muscular rigidity may be lacking despite the presence of chemical or infectious peritoneal irritation. This is partially attributed to the relatively thin abdominal musculature of older patients.78 Disturbingly, of patients over the age of 70 with a perforated ulcer, only 21 percent had epigastric rigidity. 6

• Rectal Examination: This should be performed routinely, and the detection of occult blood should receive follow-up evaluation. In one series of patients over the age of 50, some 10 percent of those discharged from the ED with a diagnosis of nonspecific abdominal pain were diagnosed with cancer, principally of the large bowel, within a year.14

• Further Examination: There should be careful inspection for hernias, particularly of the femoral canal in the older female patient. Aortic dissection may manifest with unequal femoral pulses. The back should be inspected for herpes zoster. Genital and pelvic examinations may reveal the cause of pain. Assessment of the heart and lungs may yield clues to a nonabdominal cause of the pain.

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