Initial Evaluation

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The initial evaluation of a patient with abdominal pain is extremely important. The physician's ability to collect a comprehensive medical history and perform a complete physical examination in a timely fashion is now often eclipsed and compromised by the facility of ordering a radiologic or serologic test and expecting that a single test will give the diagnosis. Although the sensitivity and specificity with which many tests can now aid in diagnosis often range in the upper 90th percentile, it is important to remember that these tests only serve as an aid to the physician. Nothing can replace a well-performed physical examination. For example, in the initial scenario, the patient is a young male who presents with classic signs and symptoms of acute appendicitis. Upon arrival to a medical treatment facility, some physicians may automatically start this patient on a care map where he gets laboratory tests drawn and then begins drinking his oral contrast for the inevitable computed tomography (CT) scan. However, many would argue that based on the strength of his physical examination and blood work, this patient could be taken to the operating room with confidence that the correct surgery was being performed.1

Key elements in the initial assessment include collecting a complete patient history. This includes the patient's past medical history including previous diagnoses, hospitalizations, or a history of trauma. Drug allergies and medications, including prescribed drugs and over-the-counter substances should also be noted. Family history and social history for any illegal substance, tobacco, or alcohol use as well as the patient's profession may also give clues to the diagnosis. One should ask about any recent sick contacts as well as recent travel history. The past surgical history will automatically rule out some diagnoses, that is, a patient cannot have appendicitis if the appendix is already out; and it will provide a clue as to some diagnoses that should be ranked higher on the list of differentials, that is, adhesions as a possible cause of small bowel obstruction in someone who has had abdominal surgery.

In addition to past medical history, a complete description of the patient's current problem should be elicited. This includes a description of the pain and symptoms. The time of onset, the length and duration of the pain, and whether it is constant or intermittent should all be recorded. One should inquire about the quality of the pain whether it is sharp and stabbing or more colicky. When initially asked about location of pain, patients may describe that their abdomen hurts diffusely. However, when probed further patients often can locate a single point where the pain is worst. Pain may also radiate to a different area, such as in cholecystitis, which can start in the right upper quadrant and then radiate up to the right shoulder, caused by diaphragmatic irritation from the inflamed gallbladder.

Along with the pain, there will be other symptoms that can help form a differential diagnosis. This includes a history of nausea and vomiting, diarrhea, constipation, and hematochezia. Nausea and vomiting may give clues to ileus or pancreatitis. Diarrhea can be secondary to an infectious etiology, food poisoning, acute mesenteric ischemia, or obstruction. Constipation from chronic dysmotility can cause abdominal pain significant enough to present as an acute abdomen. And people who present with hematochezia should always be worked up for potential malignancy. It can also be caused by infection or ischemia.

It is also important to look at the vital signs and the overall state of the patient. Before beginning the directed physical examination, look at the patient. Are they lying still because any movement causes extreme abdominal pain, implying peritoneal irritation? Or are they writhing around and rocking from side to side because they cannot seem to get comfortable, implying a more colicky pain caused by colonic distention or a kidney stone? Are they lying with their knees bent or in a slightly folded over position because it hurts to straighten out? Is the patient febrile, tachycardic, or hypotensive? Patients who present with the complaint of abdominal pain usually have been experiencing the pain for a substantial amount of time before they present to a physician. Patients will often believe that they have the flu, menstrual cramps, or some other more common etiology before they realize that the pain has not gone away and is actually worse. As a result, they often present late in the course of their illness. They may be dehydrated and potentially can be septic.

A thorough physical examination should include auscultation to listen for hypo or hyperactive bowel sounds. Palpation should be of the four main quadrants to look for guarding and rebound tenderness. Begin away from the quadrant to which the patient localizes the worst pain. A digital rectal examination should be performed in order to check for any blood in the stool, presence or absence of stool in the rectal vault, as well as to check for pelvic peritoneal signs. The patient should be examined for previous surgical scars and should be checked for any hernias, including inguinal and femoral, that could potentially be the source of pain secondary to incarceration. While performing the examination, keep in mind any recent pain medication the patient has received or if the patient is chronically immunosuppressed or on steroids, which could potentially dampen physical findings.

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