Clinical Evaluation. Physical Examination

History should include the quality, timing, and type of abdominal pain.
Pain of sudden onset often denotes colic, perforation or acute ischemia caused by torsion or volvulus.
Slower onset of pain suggests inflammatory conditions, such as appendicitis, pancreatitis, or cholecystitis.
Chronic pain can occur with non-surgical conditions or with early problems that are potentially surgical.

Colic results from spasms of a hollow viscus organ secondary to an obstruction. It is characterized by severe, intermittent cramping, followed by intervals when the pain is present but less intense. When spasms are present, the patient will appear agitated and restless, pale and diaphoretic. Colic pain usually originates from the biliary tree, pancreatic duct, gastrointestinal tract, urinary system, or uterus and tubes.

Inflammatory pain is caused by peritoneal irritation, and the patient presents quietly without much motion and appears ill. The pain is initially less severe and is exacerbated by movement.

Vomiting
The timing of the onset of vomiting is important. Usually abdominal pain will precede vomiting.
The interval between abdominal pain and vomiting is shorter when associated with colic.
Delayed vomiting for many hours is often associated with distal bowel obstruction or ileus secondary to peritonitis.

Diarrhea

Mild diarrhea with the onset of abdominal pain suggests acute gastroenteritis or early appendicitis.
Delayed onset of diarrhea may indicate a perforated appendicitis, with the inflamed mass causing irritation of the sigmoid colon.
Pain medications
Physical Examination

The abdomen should be observed, auscultated, and palpated for distention, localized tenderness, masses, and peritonitis. The groin must be examined to exclude an incarcerated hernia or ovary, or torsion of an ovary or testicle.

Rectal Examination

Gross blood in the stool suggests ectopic gastric mucosa, Meckel’s diverticula, or polyps.

Blood and mucus (currant jelly stool) suggests inflammatory bowel disease or intussusception.

Melena suggests upper gastrointestinal bleeding, necessitating gastric aspiration for blood.

Tests for occult blood in the stool should be performed.

Pelvic examinations are mandatory for postmenarchal and/or sexually active female patients. The rectal examination may also be used to evaluate the cervix, uterus, adnexa, and other pelvic masses.

Fever

Thoracic disease (eg, pneumonia) may be the cause of abdominal pain associated with fever.

Costovertebral angle tenderness with fever suggests pyelonephritis or a high retrocecal appendicitis.

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