Description
A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ; however, as a precaution, the doctor ordered a CTA scan.
Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.
In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible
The Episodic Note Case Study: Abdominal Assessment
This is the HALF WAY POINT!
LAB ASSIGNMENT: ASSESSING THE ABDOMEN
A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ; however, as a precaution, the doctor ordered a CTA scan.
Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.
In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible
RESOURCES
Be sure to review the Learning Resources before completing this activity.
REVIEW the Weekly Resources List to access the resources.
TO PREPARE
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
With regard to the Episodic note case study provided:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
SEE EPISODIC SOAP NOTE, BELOW
ABDOMINAL ASSESSMENT
Subjective:
CC: “My stomach has been hurting for the past two days.”
HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.
PMH: HTN
Medications: Metoprolol 50mg
Allergies: NKDA
FH: HTN, Gerd, Hyperlipidemia
Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female
Objective:
VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound. Diagnostics: US and CTA
Assessment:
Abdominal Aortic Aneurysm (AAA)
Perforated Ulcer
Pancreatitis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
***Please DO NOT recopy this SOAP note to your assignment for Submission.
THE ASSIGNMENT
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
This should be a paper with subheadings, please use subheadings below. This makes your papers a lot easier to read and ensures you are answering all the questions on the Rubric. Be sure to answer all information to receive maximum points. Subjective Portion Objective Portion Assessment Supported Diagnostic Tests Rejection or Acceptance Possible ConditionsThis should be written as a narrative/paragraphs only!DO NOT rewrite a SOAP note.Tell me what’s wrong with the Episodic SOAP Note, by responding to the statements/questions above.
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
NURS_6512_Week_6_Assignment_1_Rubric
NURS_6512_Week_6_Assignment_1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeWith regard to the SOAP note case study provided, address the following:Analyze the subjective portion of the note. List additional information that should be included in the documentation.
12 to >9.0 pts
Excellent
The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.
9 to >6.0 pts
Good
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.
6 to >3.0 pts
Fair
The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP note and vaguely and/or with some inaccuracy lists additional information to be included in the documentation.
3 to >0 pts
Poor
The response inaccurately analyzes or is missing analysis of the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
12 pts
This criterion is linked to a Learning OutcomeAnalyze the objective portion of the note. List additional information that should be included in the documentation.
12 to >9.0 pts
Excellent
The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.
9 to >6.0 pts
Good
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.
6 to >3.0 pts
Fair
The response vaguely and/or with some inaccuracy analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.
3 to >0 pts
Poor
The response inaccurately analyzes or is missing analysis of the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
12 pts
This criterion is linked to a Learning OutcomeIs the assessment supported by the subjective and objective information? Why or why not?
16 to >13.0 pts
Excellent
The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.
13 to >10.0 pts
Good
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation.
10 to >7.0 pts
Fair
The response vaguely and/or inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.
7 to >0 pts
Poor
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
16 pts
This criterion is linked to a Learning OutcomeWhat diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
20 to >17.0 pts
Excellent
The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.
17 to >14.0 pts
Good
The response accurately describes appropriate diagnostic tests for the case and explains clearly and accurately how the test results would be used to make a diagnosis.
14 to >11.0 pts
Fair
The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.
11 to >0 pts
Poor
The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.
20 pts
This criterion is linked to a Learning Outcome· Would you reject or accept the current diagnosis? Why or why not?· Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
25 to >22.0 pts
Excellent
The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature.
22 to >19.0 pts
Good
The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained accurately using three different references from current evidence-based literature.
19 to >16.0 pts
Fair
The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two or three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidence-based literature.
16 to >0 pts
Poor
The response inaccurately or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies two or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using three or fewer references from current evidence-based literature.
25 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.0 pts
Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
3 to >2.0 pts
Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. 5 pts This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
2 to >0 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 pts
Excellent
Uses correct APA format with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) APA format errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) APA format errors.
2 to >0 pts
Poor
Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100
Learning Resources
Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 18, “Abdomen”
In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 3, “Abdominal Pain
This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis.
Chapter 10, “Constipation”
The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.
Chapter 12, “Diarrhea”
In this chapter, the authors focus on diagnosing the cause of diarrhea. The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform.
Chapter 29, “Rectal Pain, Itching, and Bleeding” This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.
These sections below explain the procedural knowledge needed to perform gastrointestinal procedures
.Chapter 115, “X-Ray Interpretation of Abdomen” pp. (514–520)
Unformatted Attachment Preview
CHAPTER 3
Abdominal pain
Abdominal pain is a subjective feeling of discomfort in the abdomen that can be caused by a variety of
problems. The goal of initial clinical assessment is to distinguish acute lifethreatening conditions from
chronic/recurrent or acute mild, selflimiting conditions. Assessment is complicated by the dynamic rather than
static nature of acute abdominal pain, which can produce a changing clinical picture, often over a short period
of time. In addition, both children and older adults tend to deviate from the usual and anticipated clinical
pattern of abdominal pain. The following three processes can produce abdominal pain: (1) tension in the
gastrointestinal (GI) tract wall from muscle contraction or distention, (2) ischemia, and (3) inflammation of the
peritoneum. Pain can also be referred from within or outside the abdomen.
Colic is a type of tension pain. It is associated with forceful peristaltic contractions and is the most
characteristic type of pain arising from the viscera. Colicky pain can be produced by an irritant substance, from
infection with a virus or bacteria, or by the body’s attempt to force its luminal contents through an obstruction.
Another type of tension pain is caused by acute stretching of the capsule of an organ, such as the liver, spleen,
or kidney. The patient with this visceral pain is restless, moves about, and has difficulty getting comfortable.
Ischemia produces an intense, continuous pain. The most common cause of intestinal ischemic pain is
strangulation of the bowel from obstruction.
Inflammation of the peritoneum usually begins at the serosa covering the affected and inflamed organ,
causing visceral peritonitis. The pain is a poorly localized aching. As the inflammatory process spreads to the
adjacent parietal peritoneum, it produces localized parietal peritonitis. The pain of parietal peritonitis is more
severe and is perceived in the area of the abdomen corresponding to the inflammation. A patient with parietal
pain usually lies still and does not want to move.
Pain can be referred from within the abdomen or from other parts of the body (Box 3.1).
Box 3.1
Some Causes of Pain Perceived in Anatomical Regions
Right upper quadrant
• Duodenal ulcer
• Hepatitis
• Hepatomegaly
• Pneumonia
• Cholecystitis
Right lower quadrant
• Appendicitis
• Salpingitis
• Ovarian cyst
• Ruptured ectopic pregnancy
• Renal or ureteral stone
• Strangulated hernia
• Meckel diverticulitis
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• Regional ileitis
• Perforated cecum
Periumbilical
• Intestinal obstruction
• Acute pancreatitis
• Early appendicitis
• Mesenteric thrombosis
• Aortic aneurysm
• Diverticulitis
Left upper quadrant
• Ruptured spleen
• Gastric ulcer
• Aortic aneurysm
• Perforated colon
• Pneumonia
Left lower quadrant
• Sigmoid diverticulitis
• Salpingitis
• Ovarian cyst
• Ruptured ectopic pregnancy
• Renal or ureteral stone
• Strangulated hernia
• Perforated colon
• Regional ileitis
• Ulcerative colitis
Modified from Judge R, Zuidema G, Fitzgerald F: Clinical diagnosis, ed. 5, Boston, 1988, Little Brown.
Referral of pain occurs because tissues supplied by the same or adjacent neural segments have the same
common pathways inside the central nervous system. Thus, stimulation of these neural segments produces the
sensation of pain. For example, nerves that supply the appendix are derived from the same source as those that
supply the small intestine, resulting in the onset of appendicitis pain in the epigastric area.
Abdominal pain in adults can be classified as acute, chronic, or recurrent. The term “acute abdomen” refers to
any acute condition within the abdomen that requires immediate attention because surgical intervention may be
required. Acute abdominal pain refers to a relatively sudden onset of pain that is severe or increasing in severity
and has been present for a short duration. Chronic pain is characterized by its persistent duration or recurrence.
Recurrent episodes of pain can be either acute or chronic in nature.
In adults, acute pain requiring immediate surgical intervention is commonly caused by appendicitis,
perforated peptic ulcer, intestinal obstruction, peritonitis, perforated diverticulitis, ectopic pregnancy, or
dissection of aortic aneurysm. Other common causes of acute pain include cholelithiasis, gastroenteritis, peptic
gastroduodenal syndrome, pancreatitis, pelvic inflammatory disease (PID), or urinary tract infection (UTI).
Chronic or recurrent pain can be caused by GI disorders, such as Crohn disease, irritable bowel syndrome (IBS),
diverticulitis, or esophagitis; pelvic disorders, such as dysmenorrhea or uterine fibroids; genitourinary
disorders, such as recurrent UTI or chronic prostatitis; or conditions outside the abdomen, such as
costochondritis, hip disease, or hernia.
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In children, abdominal pain can be classified as acute or recurrent. Common causes of acute pain include
appendicitis, food poisoning, UTI, viral gastroenteritis, and bacterial enterocolitis. Recurrent abdominal pain
(RAP) is defined as more than three episodes of pain in 3 months in children older than 3 years. It affects 10% to
15% of children between the ages of 3 and 14 years; of these children, 90% will not have an organic etiology.
Diagnostic reasoning: Focused history
Is this an acute condition?
Key Questions
• How long ago did your pain start?
• Was the onset sudden or gradual?
• How severe is the pain (on a scale of 1–10)?
• If a child: What is the child’s level of activity?
• Does the pain wake you up from sleep?
• What has been the course of the pain since it started? Is it getting worse or better?
• When was your last bowel movement?
• Have you ever had this pain before? What was diagnosed? How was it treated?
Onset and duration
Acute onset of pain that is getting progressively worse could signal a surgical emergency. In general, patients
who present with severe pain 6 to 24 hours from the onset probably have an acute surgical condition. Acute
abdominal pain can signal a few potentially lifethreatening conditions that must be considered first. The
following are possible surgical emergencies that require immediate evaluation and intervention:
• Perforation or ruptured appendix: look for signs and symptoms of peritonitis (Box 3.2)
• Ectopic pregnancy: suspect in any woman of childbearing age
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• Obstruction: sudden onset of crampy pain usually in umbilical area
• Ruptured abdominal aortic aneurysm: when back pain is present
• Intussusception: in infants
• Malrotation: in infants usually younger than 1 month old
Box 3.2
Features of Peritonitis
P
Pain: front, back, sides, shoulders
E
Electrolytes fall; shock ensues
R
Rigidity or rebound of anterior abdominal wall
I
Immobile abdomen and patient
T
Tenderness with involuntary guarding
O
Obstruction
N
Nausea and vomiting
I
Increasing pulse rate, decreasing blood pressure
T
Temperature falls and then rises; tachypnea
I
Increasing girth of abdomen
S
Silent abdomen (no bowel sounds)
Modified from Shipman JJ: Mnemonics and tactics in surgery and medicine, ed. 2, Chicago, 1984, Mosby.
Pain of sudden onset is more likely associated with colic, perforation, or acute ischemia (torsion, volvulus).
Slower onset of pain generally is associated with inflammatory conditions, such as appendicitis, pancreatitis,
and cholecystitis.
Acute pain that comes and goes can be related to intestinal peristalsis. The onset of pain in relation to food
ingestion provides diagnostic clues: pain occurring several hours after a meal suggests a duodenal ulcer (pain
with stomach empty), but pain immediately after eating occurs with esophagitis.
In children, RAP occurs in attacks usually lasting less than 1 hour and rarely longer than 3 hours and
frequently interferes with daily routines. Between episodes, the pain resolves completely. When interviewing a
child, remember that the child might not be old enough to have a clear sense of time.
Severity and progression
Severity is the most difficult symptom to evaluate because of its subjective quality. It is helpful to use a scale of 1
to 10 in adults. Children often respond to the use of the FACES pain scale or the Oucher pain scale (Fig. 3.1).
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OUCHER
10 – 9–
8–
7–
6 —
5–
4 —
3–
2 —
1 —
0 —
A
African American
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OUCHER
10 – –
9
—
8
—
7
—
6
—
s -4
—
3 —
B
2
—
1
—
0
-White
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FIGURE 3.1 The Oucher Pain Scale illustrated with African American (A), white (B), and Hispanic
(C) children to best fit the child’s cultural identity. The African American child version of the
Oucher was developed and copyrighted in 1990 by Mary J. Denyes, PhD, RN, FAAN (Wayne
State University) and Antonia Villarruel, PhD, RN, FAAN (University of Michigan) at the Children’s
Hospital of Michigan. Cornelia P. Porter, PhD, RN and Charlotta Marshall, MSN, RN contributed
to the development of this scale. The white child version of the Oucher was developed and
copyrighted in 1983 by Judith E. Beyer, PhD, RN, currently at Graceland University School of
Nursing in Independence, Missouri. Photographs were taken by Lynn Juliano, RN, BSN at Martha
Jefferson Hospital in Charlottesville, Va. The Hispanic child version of the Oucher was developed
and copyrighted in 1990 by Antonia M. Villarruel, PhD, RN (University of Michigan) and Mary J.
Denyes, PhD, RN (Wayne State University). Photographs were taken at Children’s Hospital of
Michigan in Detroit.
Determine whether the pain is an acute episode or a chronic or recurrent episode. Acute abdominal pain
requires immediate attention because it can signal an acute surgical condition in the abdomen. Chronic or
recurrent episodes of pain can be handled in a more temperate manner.
Pain that is steady, severe, and progressive is worrisome. Pain that causes one to awake from sleep is serious.
A sudden pain severe enough to cause fainting suggests perforated ulcer, ruptured aneurysm, or ectopic
pregnancy. A severe knifelike pain usually indicates an emergency. Tearing pain is characteristic of an aortic
aneurysm. Appendicitis is often described as an initial ache that gets progressively worse. Colicky pain that
becomes steady can indicate appendicitis or strangulating intestinal obstruction.
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Children are poor historians regarding the severity of pain. The caregiver should indicate how severe the
child’s pain is by a description of the activity level of the child. In general, avoidance of favorite activities or
motion indicates an organic problem. Organic disease awakens the child from sleep.
Last bowel movement
Obstipation (the absence of stools) occurs with complete obstruction, but diarrhea can be present with partial
obstruction. Lack of a bowel movement for 3 days could signal constipation. Children have a poor sense of stool
patterns and may not know what it means to be constipated. Parents often do not recognize abnormal stooling
patterns in the child. The onset of constipation can cause severe abdominal pain.
Previous pain
Chronic pain could result when a potential surgical event is partially controlled but is not totally resolved.
Chronic pain that has been present for longer than 1 year generally is not caused by a neoplasm; consider
instead IBS or colorectal, endometrial, or inflammatory causes.
Recurrent attacks of acute pain could be caused by inflammation and exacerbation of a chronic condition,
such as functional colonic pain, IBS, cholecystitis, chronic pancreatitis, diverticulitis, or ulcer disease. Other
causes of acute attacks of pain are recurrent infection, such as pyelonephritis or cystitis, and urinary tract stones.
Will the location of pain give me any clues?
Key Questions
• Where is the pain? Can you point to it?
• Does it travel (radiate) anywhere?
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Location of the pain
The viscera are innervated bilaterally so that pain is perceived in the midline. It is often described as a deep,
dull, diffuse pain. Visceral pain originates from epigastric, periumbilical, and hypogastric causes; from
intraabdominal, extraperitoneal organs (pancreas, kidneys, ureters, great vessels, pelvic organs); or from a
referred source.
Parietal (also known as peritoneal or somatic) pain is more localized and is described as a sharp pain. Parietal
pain originates from intraabdominal and intraperitoneal organs.
Inflammation (e.g., with appendicitis) can produce either visceral or parietal peritonitis. Initially, the
inflammation is limited to the serosa covering an inflamed organ. The pain is visceral and is felt diffusely. As
the inflammation progresses to the adjacent parietal peritoneum, it produces a more severe localized pain that is
perceived in the corresponding area of the abdomen. Children generally have a poor ability to localize pain and
are not helpful in the majority of cases.
The Apley rule states that the further the localization of pain from the umbilicus, the more likely it is that
there is an underlying organic disorder.
When blood, pus, or gastric fluid suddenly floods the peritoneal cavity, the pain is frequently reported as “all
over the abdomen” at first. However, the maximum intensity of pain at the onset is likely to be in the upper
abdomen with gastric problems and in the lower abdomen with tubal and appendix rupture. Irritating fluid
from a perforated duodenal ulcer produces pain in the right hypochondrium, lumbar, and iliac regions.
Pain arising from the small intestine is felt in the epigastric and umbilical areas of the abdomen. The 9th and
11th thoracic nerves supply the small intestine via the common mesentery nerve. Appendicular nerves are
derived from the same source as those that supply the small intestine, resulting in the onset of pain in the
epigastric area with appendicitis.
Table 3.1 describes the structures involved in specific pain locations.
Table 3.1
Pain Location and Involved Structures
PAIN
LOCATION
INVOLVED STRUCTURES
Epigastric
Esophagus, stomach, duodenum, liver, gallbladder, pancreas, spleen
Upper abdominal Esophagus, stomach, duodenum, pancreas, liver, gallbladder, or thorax
Right upper
quadrant
Usually esophagus, stomach, duodenum, pancreas, liver, gallbladder, or thorax; often
indicates acute cholecystitis
Left upper
quadrant
Spleen
Periumbilical
Jejunum, midgut, ileum, appendix, ascending colon; pain caused by inflammation,
ischemic spasm, or abnormal distention
Lower abdominal Colon, sigmoid colon, rectum, and genitourinary structures—bladder, uterus, prostate
Right lower
quadrant
Appendix, fallopian tube, ovary
Left lower
quadrant
Sigmoid colon, fallopian tube, ovary
Flanks
Kidney(s)
Localized
Occurs from local inflammation of skin or peritoneum, as with appendicitis; lateralized
pain occurs in paired organs—kidneys, ureters, fallopian tubes, gonads
Generalized
Produced by diffuse inflammation of gastrointestinal tract, peritoneum, or abdomen wall
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Radiation of pain
Radiation of pain can help in diagnosis. Pain that radiates will do so to the area of distribution of the nerves
coming from that segment of the spinal cord that supplies the affected area. Whereas biliary colic or gallbladder
pain is frequently referred to the region just under the right scapula (eighth dorsal segment), renal colic in males
is frequently felt in the testicle of the same side. Pain from a ruptured spleen is often referred to the top of the
left shoulder.
What do the pain characteristics tell me?
Key Questions
• Can you describe the pain (e.g., burning, sharp, achy, crampy)?
• What makes it worse or better?
Character of pain
Colicky or cramping pain occurs with obstruction of a hollow viscus that produces distention. Generally, there
are painfree intervals when the pain is much less intense but still present, although it is subtle. During the
painful episodes, the patient is exceedingly agitated and restless and often pale and diaphoretic. The pain from
obstruction of the small intestine is rhythmic, peristaltic pain with intermittent cramping. When the obstruction
site is in the proximal small intestine rather than in the more distal portion, the paroxysms of cramping occur
with greater frequency.
Steady pain is associated with perforation, ischemia, inflammation, and blood in the peritoneal cavity.
Burning pain is characteristic of esophagitis. Pain from a duodenal ulcer has been described as burning or
“gnawing.” Pain of pancreatic origin is steady, epigastric, and prostrating. Pricking, itching, or burning pain
comes from superficial causes such as herpes zoster. Dull, aching pain indicates deeper pain. In children,
abdominal pain is generally characterized as colicky or inflammatory.
Remember, however, that despite descriptions of characteristic or typical abdominal pain, presentation in
children and older adults is often atypical and might not fit any pattern.
Precipitating or aggravating factors
Lying down or bending forward often produces pain from esophagitis. Alcohol can aggravate gastritis or an
ulcer. Eating before sleeping can aggravate gastroesophageal reflux.
Pain that is made worse by deep inspiration and is stopped or diminished by a respiratory pause indicates a
pleuritic origin. If the cause is peritonitis, intraperitoneal abscess, or abdominal distention from intestinal
obstruction, pain will increase on deep inspiration. Biliary colic is made worse by forced inspiration. The pain
from biliary colic often causes inhibition of movement of the diaphragm.
A patient with visceral pain is restless, moves about, and has difficulty getting comfortable. A patient with
parietal pain usually lies still and does not want to move. Children with inflammatory pain secondary to
peritoneal irritation usually appear quiet and motionless because movement exacerbates the pain.
Relieving factors
Food or antacids can relieve pain caused by an ulcer or gastritis. Antacids often relieve pain from
gastroesophageal reflux disease (GERD). Both colicky pain and inflammatory pain are alleviated significantly
with analgesics. However, the pain of a vascular accident will not respond to analgesics.
Are there any precipitating events that will help narrow my diagnosis?
Key Questions
• Is the pain related to any other activity (e.g., eating, lying down)?
• Can you identify any trigger?
Relation to other events
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Pain that is relieved by defecation, flatus, laxatives, or diet changes implicates the intestine. Pain associated with
meals implicates the GI tract.
Pain with sexual activity (dyspareunia) suggests a pelvic origin. Pain that occurs with position changes can be
referred from the spine, hips, sacroiliac joint, pelvic bones, or abdominal musculature. Exertional pain can be of
cardiac origin.
What does the presence of vomiting or diarrhea tell me?
Key Questions
• Are you vomiting? Did the vomiting start before or after the pain?
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• What does the vomitus look like?
• What do your stools look like?
• How frequent are your stools?
Vomiting
Vomiting that precedes the onset of abdominal pain is unlikely to signal a problem requiring surgery. Vomiting
suggests that the pain is visceral in origin. Anorexia is a nonspecific symptom, but its absence makes serious
disease less likely.
Vomiting associated with an acute condition of the abdomen may be from one of the following three causes:
• Severe irritation of the nerves of the peritoneum or mesentery. Sudden stimulation of many
sympathetic nerves causes vomiting to occur early and to be persistent.
• Obstruction of an involuntary muscular tube. Obstruction of any of the muscular tubes causes
peristaltic contraction and consequent stretching of the muscle wall, which results in vomiting. The
area behind the obstruction becomes dilated, and as each peristaltic wave occurs, the tension and
stretching of the muscular fibers are temporarily increased; therefore, the pain of colic usually occurs
in spasms. Vomiting usually occurs at the height of the pain.
• The action of absorbed toxins on the medullary centers. The chemoreceptor trigger zone is stimulated
by drugs such as cardiac glycosides, ergot alkaloids, and morphine or by uremia, diabetic
ketoacidosis, or general anesthetics. Impulses to the medullary vomiting center activate the vomiting
process.
Pain with vomiting
In sudden and severe stimulation of the peritoneum or mesentery, vomiting comes soon after the pain. In acute
obstruction of the urethra or bile duct, vomiting is early, sudden, and intense. In intestinal obstruction, the
timing of the vomiting indicates the location of the obstruction. If the duodenum is obstructed, vomiting occurs
with the onset of pain. Obstruction of the large bowel causes very late or infrequent vomiting.
Vomiting is not usually seen in ectopic pregnancy, gastric or duodenal perforation, or intussusception.
Vomiting occurring before pain indicates gastroenteritis. With appendicitis, pain almost always precedes the
vomiting.
Appearance of vomitus
Clear vomitus suggests gastric fluid; bilecolored vomitus is from upper GI contents. Feculent vomitus occurs
with distal intestinal obstruction. Coffee grounds or black color indicates GI bleeding. Patients with gastric
outlet obstruction vomit fluid that contains food particles if the patient has eaten recently, but later the vomitus
becomes clear. Infants with duodenal atresia and small bowel volvulus will vomit bilious fluid, but in pyloric
stenosis, no bile is seen.
Diarrhea
Diarrhea (see Chapter 12) is associated with inflammatory bowel disease (IBD), IBS, diverticulitis, early
obstruction, or infection. The presence of blood in the stool suggests that the pain originates in the intestinal
tract. Blood can indicate neoplasm, intussusception, inflammatory lesions, or an invasive organism.
Diarrhea can precede perforation of the appendix as a result of irritation of the sigmoid colon by an
inflammatory mass. Some patients will report gas stoppage symptoms: the sensation of fullness that suggests
the need for a bowel movement. With appendicitis, the patient often attempts to defecate but without relief.
In children, mild diarrhea associated with the onset of pain suggests acute gastroenteritis but can also occur
with early appendicitis. A lowlying appendix, close to the sigmoid colon and rectum, can induce an
inflammatory process of the muscle wall of the sigmoid colon. Any distention of the sigmoid by fluid or gas,
signals the child to pass gas and small amounts of stool. The cycle repeats a few minutes later. In gastroenteritis,
typically the child will have large liquid stools. Children can also have abdominal pain from chronic
constipation. Constipation that precedes pain suggests disease of the colon or rectum.
Are there any clues to implicate a particular organ system?
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If the patient gives a positive response to the following history questions, refer to the topic or chapter indicated
for additional discussion. Pain that is not abdominal in origin could be referred to or perceived to be in the
abdomen. Accompanying symptoms of headache, sore throat, and general aches and pains suggest a viral,
flulike cause.
Key Questions
Cardiovascular system (see Chapter 8):
• Does the pain occur with exertion or at rest?
• Do you have any chest pain, palpitations, fast heartbeat, or pain that goes to the arm or jaw?
Referred pain from the chest is common. Pain on exertion signals coronary artery disease (CAD) and angina.
Right upper quadrant (RUQ) pain can be caused by congestive heart failure. Myocardial infarction (MI) and
pericarditis can also cause abdominal pain.
Key Questions
Gastrointestinal system (see Chapters 10 and 12):
• Do you have any GI symptoms (e.g., gas, diarrhea, constipation, vomiting, heartburn)?
• Have you had any changes in your bowel habits, stools, or eating pattern?
• Is the pain relieved by defecation or burping?
Gas, bloating, diarrhea, constipation, and rectal bleeding can occur with pain that is intestinal in origin.
Heartburn and dysphagia are characteristic of esophagitis and GERD. Changes in bowel habits can signal
obstruction or neoplasm. Constipation alternating with diarrhea is characteristic of IBS. The patient often also
reports distention, bloating, belching, gas, and mucus in the stools.
Pain relieved by defecation or the passage of gas suggests IBS or gas entrapment in the large intestine. Pain
relieved by burping suggests distention of the stomach by gas.
Key Questions
Genitourinary system (see Chapters 5, 18, 27, and 35 to 37):
• When was your last menstrual period (LMP)? Was it normal for you? Could you be pregnant?
• Do you have any vaginal symptoms or problems, such as unusual discharge, unusual bleeding, or
pain with sexual intercourse?
• Do you have any menstrual irregularity or unusual bleeding? (Sexual history could provide
information relevant to the possibility of sexually transmitted infections [STIs], PID, and pregnancy.)
• Do you have any urinary symptoms (e.g., frequency, urgency, dysuria, blood in urine, change in urine
color)?
• Do you have pain in the back (flank)? Can you point to it?
Menstrual irregularities, vaginal discharge, unusual bleeding, or dyspareunia indicates a pelvic origin of the
pain. Sexually active adolescent girls are at the highest risk for contracting PID. Patients with PID may complain
of both vaginal discharge and abnormal vaginal bleeding, although pain is often the only presenting symptom.
The pain is usually severe and progressive. Pain just before the onset of menses indicates endometriosis. Pain
related to ovulation (mittelschmerz) occurs midcycle. In women of childbearing age, always consider ectopic
pregnancy. Regard women of childbearing age as pregnant until pregnancy is ruled out.
Urinary symptoms (dysuria, hematuria, hesitancy, or frequency) point to a urinary tract cause of the pain. In
young children abdominal pain and vomiting may be signs of a UTI. Flank pain is usually associated with renal
calculi or pyelonephritis. Upper abdominal pain that radiates to the groin signals ureterolithiasis.
Key Questions
Musculoskeletal system (see Chapters 22 to 24):
• Does the pain occur with change in position or movement?
• Do you have any joint pain, heat, swelling, noises, or limitation in range of motion?
• Do you have any difficulty walking?
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Pain produced by musculoskeletal problems and referred to the abdomen can be provoked by position
changes or walking. Costochondritis can produce pain with respiration. Symptoms of joint involvement point to
either a local cause with referred pain, or a systemic cause, such as rheumatoid arthritis.
Key Questions
Respiratory system (see Chapters 11 and 14):
• Do you have a cough or difficulty breathing?
• Do you have any shortness of breath?
• Does the child complain of a sore throat?
Pneumonia, especially of a lower lobe, is a common cause of pain perceived in the abdomen, especially in
children. Pleurisy can produce pain on deep inspiration. Persistent coughing can produce musculoskeletal
soreness that may be referred to the abdomen. Children with strep throat may present with abdominal pain.
Is the pain psychogenic, organic, or functional?
Key Questions
• Do you feel unhappy, sad, depressed?
• Are you able to eat, sleep, or engage in usual activities?
• Have you had recent problems with diarrhea or constipation?
• How is your energy level?
• Have you ever been diagnosed with or treated for a mental health or psychiatric problem?
Abdominal pain can be functional or psychogenic in origin and presents somewhat differently from organic
pain (Table 3.2). In children, functional abdominal pain is caused by one of four or a combination of more than
one of the following: functional dyspepsia, functional abdominal pain syndrome, IBS, or abdominal migraine.
Table 3.2
Organic versus Functional Pain
HISTORY
ORGANIC PAIN
FUNCTIONAL PAIN
Pain character
Acute, persistent pain increasing in
intensity
Less likely to change or get more
severe
Pain localization
Sharply localized
Various locations
Pain in relation to
sleep
Awakens at night
Does not affect sleep
Pain in relation to
umbilicus
Farther away
At umbilicus
Associated symptoms
Fever, anorexia, vomiting, weight loss,
anemia, elevated ESR
Headache, dizziness, and multiple
system complaints
Psychological stress
None reported
Present
The presence of vegetative symptoms suggests depression (see Chapter 4).
What else do I need to consider?
Key Questions
• What medications (prescribed and over the counter) are you taking? Why are you taking them?
• Have you had any operations? What were they?
• Have you recently had an involuntary weight loss?
• Have you been camping?
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• If a child: Is the child in a day care setting?
Medications
Gastrointestinal distress is a common adverse reaction to many medications. Erythromycin and tetracycline are
commonly associated with abdominal pain. Aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) can
cause pain associated with gastritis and ulcer formation.
Surgery
Prior surgery can produce adhesions that cause intestinal obstruction. Adhesion of organs to the abdominal
wall can also produce pain. Prior appendectomy does not preclude appendicitis; the stump can become
inflamed.
Involuntary weight loss
Involuntary weight loss raises the index of suspicion for colon cancer. Identify other factors that would lead you
to suspect neoplasms, such as a recent change in bowel habits in a middleaged patient, family history of
colorectal or gynecologic cancer, and the presence of blood in the stool.
Camping or day care
Ingestion of untreated water can result in intestinal parasites. Transmission of intestinal parasites is also
common in day care settings. Children with intestinal parasites may present with abdominal pain as the only
symptom; therefore, stools should be evaluated for ova and parasites.
Diagnostic reasoning: Focused physical examination
Note general appearance
Patients with visceral pain are restless, move about, and have difficulty getting comfortable. These are patients
with colicky type pain, often indicative of biliary obstruction, ureterolithiasis, obstruction, gastroenteritis, or
early peritonitis.
Patients with parietal pain usually lie still and do not want to move. These are patients with localized
peritonitis indicative of appendicitis, rupture, or perforation.
In children, note whether the child looks sick (see Chapter 17). Children can react to pain differently than
adults. With peritoneal irritation, they are typically quiet and motionless with their knees flexed and drawn up.
Children who are septic or have serious diseases, such as perforation or intussusception, generally lie still and
look lethargic, withdrawn, and apprehensive. A child with colicky pain frequently writhes in discomfort,
occasionally rocking in a rhythmic fashion.
Assess vital signs
In patients who are tachycardic and tachypneic, suspect a serious thoracic, intraabdominal, or pelvic disorder
that is producing an acute condition in the abdomen. Shallow respirations could indicate pneumonia or pleurisy
with referred pain. Orthostatic hypotension, an unusually low blood pressure, or a normal blood pressure in
someone who is usually hypertensive can indicate an acute abdominal condition.
The presence of a fever suggests an acute inflammatory condition. A temperature of greater than 39.4°C
(102.9°F) is associated more with pulmonary and renal infection than with an abdominal problem and can
indicate pneumonia or pyelonephritis.
In adults, look for documented recent involuntary weight loss, which indicates a neoplasm. Weigh a child to
determine weight loss and dehydration status.
Examine the throat
Note exudate, erythema, and
