What are the hands-on checks during a physical exam and key questions to ask a patient presenting with general abdominal pain?

Physical Examination and Key Questions for Abdominal Pain

The physical examination for abdominal pain should include inspection, auscultation, percussion, and palpation, with special attention to localized tenderness, guarding, and peritoneal signs, while key questions should focus on pain characteristics, associated symptoms, and red flag features to identify life-threatening conditions.

Physical Examination Techniques

Inspection

• Observe the abdomen for distension, visible peristalsis, pulsations, or skin changes
• Note patient positioning (patients with peritonitis often lie still while those with colic may be restless)
• Check for surgical scars, bruising, or rashes

Auscultation

• Listen for bowel sounds in all four quadrants (hyperactive, hypoactive, or absent)
• Auscultate for bruits over major vessels
• Note the quality and frequency of bowel sounds (absent sounds may suggest ileus or peritonitis) 1

Percussion

• Perform general percussion to detect tympany or dullness
• Check for liver span and splenic dullness
• Test for shifting dullness if ascites is suspected
• Assess for rebound tenderness (percussion tenderness suggests peritoneal inflammation) 2

Palpation

• Begin with light palpation away from the area of pain
• Progress to deep palpation in all four quadrants
• Check for:
  • Localized tenderness
  • Guarding (voluntary or involuntary)
  • Rigidity
  • Rebound tenderness
  • Masses or organomegaly
  • Murphy's sign (for cholecystitis)
  • McBurney's point tenderness (for appendicitis)
  • Rovsing's sign (pain in RLQ when LLQ is pressed)
  • Psoas sign (pain with extension of hip)
  • Obturator sign (pain with internal rotation of flexed hip) 2, 1

Special Examinations

• Digital rectal examination to check for:
  • Masses
  • Blood in stool
  • Tenderness
  • Prostate abnormalities in men
• Pelvic examination in women to rule out gynecological causes 2, 1

Key Questions to Ask

Pain Characteristics

1. Onset: "When did the pain start? Was it sudden or gradual?"
2. Location: "Where exactly is the pain? Does it radiate anywhere?"
3. Quality: "How would you describe the pain? (sharp, dull, cramping, burning)"
4. Severity: "On a scale of 1-10, how severe is your pain?"
5. Timing: "Is the pain constant or does it come and go?"
6. Aggravating/alleviating factors: "What makes the pain worse or better?" 1

Associated Symptoms

1. "Have you experienced nausea or vomiting? If so, what did the vomit look like?"
2. "Have you noticed any changes in your bowel movements? (diarrhea, constipation, blood)"
3. "Have you had fever or chills?"
4. "Have you noticed any changes in urination? (frequency, pain, blood)"
5. "For women: Could you be pregnant? When was your last menstrual period?" 2, 1

Medical History

1. "Do you have any previous abdominal conditions or surgeries?"
2. "Are you taking any medications, including over-the-counter drugs?"
3. "Do you have any allergies?"
4. "Do you have any chronic medical conditions?"
5. "Have you had similar pain before? If so, what was the diagnosis?" 1

Red Flag Questions

1. "Have you noticed any blood in your vomit or stool?"
2. "Have you had unexplained weight loss recently?"
3. "Have you had persistent fever?"
4. "Is the pain waking you from sleep?"
5. "Have you fainted or felt lightheaded with this pain?" 2, 1

Special Considerations

Elderly Patients

• Be aware that elderly patients often present with atypical symptoms
• Only 50% of elderly patients with acute left colonic diverticulitis have pain in the lower quadrants
• Only 17% may present with fever
• 43% may not have leukocytosis 1

Pregnant Patients

• Always perform pregnancy testing in women of reproductive age
• Beta-hCG testing is essential to rule out ectopic pregnancy
• Ultrasound should be the first imaging choice, followed by MRI if needed 1

Common Pitfalls to Avoid

1. Failing to consider extra-abdominal causes of abdominal pain (e.g., pneumonia, myocardial infarction)
2. Overlooking gynecological causes in women of reproductive age
3. Relying solely on laboratory tests without proper physical examination
4. Delaying imaging in elderly patients with acute abdominal pain
5. Repeating unnecessary tests in patients with established functional pain diagnoses 1, 3

Remember that the physical examination findings combined with a thorough history will guide appropriate laboratory and imaging studies. For patients with obvious peritonitis, immediate surgical intervention should be considered without delaying for additional imaging 2.