Mesenteric Ischemia: This condition often presents with severe abdominal pain that is disproportionate to the physical examination findings. The pain is usually diffuse and may not be accompanied by significant abdominal tenderness or guarding until late in the course.

Pancreatitis: While pancreatitis can cause significant abdominal tenderness, some patients, especially those with chronic pancreatitis or those in the early stages of acute pancreatitis, may have pain out of proportion to their exam.
Peptic Ulcer Disease: Although peptic ulcers typically cause epigastric pain and tenderness, the pain can sometimes be severe and seem disproportionate to the physical findings, especially if the ulcer is penetrating or has caused a significant inflammatory response.
Intestinal Obstruction: Early in the course of an intestinal obstruction, the physical exam may not fully reflect the severity of the pain, which can be severe and colicky.

Ectopic Pregnancy: Although more commonly associated with pelvic pain, an ectopic pregnancy can cause abdominal pain that seems out of proportion to the exam, especially if the patient is not yet showing significant peritoneal signs.
Ruptured Aortic Aneurysm: This is a life-threatening condition that can present with severe abdominal or back pain that may initially seem disproportionate to the physical findings.
Ovarian Torsion: Similar to ectopic pregnancy, ovarian torsion can cause severe pain that may not be fully reflected by the initial physical exam.

Porphyria: Acute intermittent porphyria is a rare genetic disorder that can cause severe, diffuse abdominal pain without significant findings on physical examination.
Hereditary Angioedema: This condition can cause recurrent episodes of severe abdominal pain due to angioedema of the bowel wall, which may not be accompanied by significant abdominal tenderness.
Familial Mediterranean Fever: A genetic disorder that can cause recurrent episodes of severe abdominal pain, often without significant findings on physical examination.