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CE ARTICLE Physical Exam As with any physical exam, one must develop a systemic manner in which it is done the same way each time. Although this patient presents with abdominal pain, remember that all abdominal pain does not represent an abdominal problem. For example, a patient experi- encing an inferior myocardial infarction may present with abdominal pain. A full physical exam is always warranted. The first part of the abdominal exam is done without even touching the patient. Ask the patient to expose her abdomen and perform a visual inspection. Look for visual distension, bruising, bleeding or other abnormalities. Auscultate with the stethoscope, listening for bowel sounds, noting both frequency and pitch. Pay particular attention for bruit, which is the noise made by turbulent blood flow as it passes through an obstruction in an artery. If there is no abdominal bruit, palpate the abdomen. Bruits may suggest an abdominal aortic aneurysm and palpation of the area may exacerbate the disease.5 Begin palpating the abdominal quadrant diagonally opposite the quad- rant where the patient is experiencing pain. It is important to not just palpate the abdomen, but to also look at the patient’s body posture and facial expres- sions at the same time. If the patient is not able to tolerate light palpation, there is no need to continue eliciting pain by pressing deeper on that quadrant. Look to see if the patient’s abdomen tenses up as soon as touched or if she can tolerate deep palpation before pain becomes intolerable. The inability to tolerate light palpation is a peritoneal sign, which again suggests diffuse irritation to the peritoneal lining of the abdominal cavity and may suggest pathology related to peritonitis, the most common example being appendicitis. Sometimes, perito- neal signs are best elicited when moving the stretcher into the ambulance, as even with the gentlest hands, unavoidable vibrations occur. Using the original scenario, the following cases will help illustrate different presentations of abdominal pain. Table 2: Causes of Abdominal Pain by Body System2 CARDIOVASCULAR/VASCULAR INTESTINAL TRACT Abdominal aortic aneurysm— hypotension, midline abdominal pain, palpable pulsating abdominal mass Ischemia: Anterior/inferior wall MI— diaphoresis, upper abdominal pain, tachycardia, hypo/hypertension Bowel/mesentery infarction—pain out of proportion to physical exam, bloody or tarry stools Splenic infarction—upper left-sided abdominal pain RESPIRATORY Lower lobe pneumonia—cough, diffi culty breathing, fever Pulmonary embolus—tachycardia, shortness of breath REPRODUCTIVE TRACT Ovarian torsion—excruciating, one- sided lower abdominal pain that may come and go Ovarian cyst—may present as a mass or pain, unilateral or bilateral Salpingitis/tubo-ovarian abscess— fever, abdominal pain, nausea Septic pelvic thrombophlebitis – fever, unilateral abdominal pain Endometritis – abdominal distention, vaginal discharge Endometriosis – dysmenorrhea, dyspareunia Uterine perforation—hypotension Uterine fi broids—may be painful or painless palpable masses Dysmenorrhea—time relationship to menstruation PREGNANCY-RELATED Ectopic pregnancy— hypotension, vaginal bleeding Threatened abortion—bloody discharge of cervical os, closed cervical os, no fetal parts have been passed Spontaneous abortion—passage of the fetus Ovarian hyperstimulation syndrome—bloating, weight gain Placenta previa—painless vaginal bleeding Placental abruption—painful vaginal bleeding Round ligament pain—2nd and 3rd trimester back/pelvic pain not associated with contractions Appendicitis—nausea, vomiting, fever, lower right-sided pain Diverticulitis—usually older person, sigmoidal pain Ischemic bowel—severe pain, bloody diarrhea, fever Perforated viscus—guarding, fever, hypotension, tachycardia Ulceration—pain possibly related to food, bloody emesis or stool Bowel obstruction—constipation or diarrhea, hx of abdominal surgery Incarcerated/strangulated hernia— outpouching of abdominal wall or inguinal/femoral region, tenderness Infl ammatory bowel disease—history, diarrhea Gastroenteritis—nausea, vomiting, diarrhea, fever Constipation/impaction—change in bowel habits Pancreatitis—hx of gallstones or drinking, pain radiates to back Cholecystitis—epigastric pain, particularly after fatty meals URINARY TRACT Pyelonephritis—fever, fl ank pain, nausea Cystitis—dysuria, pelvic tenderness Ureteral stone—fl ank pain that comes and goes TRAUMA Accidental and non-accidental—make sure injuries match story SYSTEMIC Diabetic ketoacidosis—known diabetic, usually type 1, fruity-smelling breath, tachypnea Alcoholic ketoacidosis—known alcoholic Uremia—hand tremors, liver disease Sickle cell disease—body pain, known sickle cell diagnosis, fever Porphyria—dark urine, photosensitivity Hyperthyroidism—weight loss, palpitations, anxiety Ingestion—hx of ingestion, nausea/ vomiting Modifi ed from Goldman L, Ausiello DA. Cecil Medicine 23rd edition, Chapter 145. EMSWORLD.com | JULY 2011 61 SECOND AND THIRD TRIMESTERS FIRST TRIMESTER