What are the steps for a paramedic to conduct an abdominal exam on a patient with generalized abdominal pain?

Paramedic Abdominal Examination for Generalized Abdominal Pain

A systematic, thorough abdominal examination is essential for paramedics to identify life-threatening conditions in patients with generalized abdominal pain, with particular attention to signs of peritonitis, ischemia, or intra-abdominal infection.

Initial Assessment

1. Scene Safety and Primary Survey

   • Ensure scene safety
   • Assess airway, breathing, circulation
   • Check vital signs (BP, HR, RR, temperature, SpO2)
   • Note signs of shock (tachycardia, hypotension)

2. Pain Assessment

   • OPQRST method:
     • Onset: Sudden vs. gradual
     • Provocation/Palliation: What makes it better/worse?
     • Quality: Sharp, dull, cramping, burning
     • Radiation: Does pain radiate elsewhere?
     • Severity: 0-10 scale
     • Timing: Constant vs. intermittent

3. Associated Symptoms

   • Nausea/vomiting (timing relative to pain)
   • Diarrhea/constipation
   • Fever
   • Urinary symptoms
   • Recent weight loss
   • Blood in stool/vomit/urine

Physical Examination Sequence

1. Observation

• Patient positioning (still vs. restless, knees drawn up)
• Facial expression (pain, distress)
• Skin color and condition (pallor, jaundice, diaphoresis)
• Abdominal distention or visible peristalsis
• Surgical scars

2. Auscultation (Before Palpation)

• Listen in all four quadrants for 30-60 seconds each
• Note bowel sounds: present, hyperactive, hypoactive, absent
• Abnormal sounds: bruits, friction rubs

3. Percussion

• Percuss all four quadrants systematically
• Note areas of tympany (gas) vs. dullness (fluid/mass)
• Assess for liver span
• Check for shifting dullness (ascites)

4. Palpation

• Light palpation first

  • Begin away from the painful area
  • Note areas of tenderness, guarding, or masses

• Deep palpation

  • Assess for organomegaly (liver, spleen)
  • Check for masses
  • Evaluate for rebound tenderness (press deeply and release quickly)
  • Murphy's sign (RUQ pain with inspiration during palpation)
  • McBurney's point tenderness (RLQ)

5. Special Tests

• Involuntary guarding test: Have patient take deep breaths while palpating - involuntary guarding persists during inspiration
• Rebound tenderness: Press deeply and release quickly - pain on release suggests peritoneal irritation 1
• Pain out of proportion: Severe pain with minimal exam findings suggests mesenteric ischemia 1

Critical Findings to Document

1. Signs of Peritonitis

   • Rebound tenderness
   • Involuntary guarding
   • Board-like rigidity
   • Pain with movement/coughing

2. Signs of Shock

   • Tachycardia
   • Hypotension
   • Altered mental status
   • Poor skin perfusion

3. Red Flags

   • Pain out of proportion to exam findings (suggests mesenteric ischemia) 1
   • Pulsatile abdominal mass (possible AAA)
   • Severe, sudden onset pain (perforation, ischemia)
   • Fever with abdominal pain (infection, abscess) 1

Communication and Documentation

1. Patient History Documentation

   • Duration and progression of symptoms
   • Previous similar episodes
   • Recent surgeries or procedures
   • Medical conditions (cardiac issues, diabetes)
   • Current medications

2. Reporting to Receiving Facility

   • Use structured handoff (SBAR)
   • Emphasize concerning findings
   • Report vital sign trends
   • Communicate interventions performed

Common Pitfalls to Avoid

1. Diagnostic Pitfalls

   • Relying solely on location of pain (referred pain is common)
   • Missing atypical presentations in elderly patients
   • Overlooking extra-abdominal causes (pneumonia, MI)
   • Assuming pain is non-urgent when exam is benign (mesenteric ischemia often presents with minimal findings) 1, 2

2. Examination Errors

   • Palpating painful areas first (increases guarding)
   • Performing percussion after palpation
   • Inadequate exposure of abdomen
   • Rushing the exam due to patient distress

Transport Decision-Making

Immediate transport is indicated for:

• Signs of shock
• Peritoneal signs
• Severe pain unresponsive to treatment
• Pain out of proportion to exam findings
• Pulsatile abdominal mass
• Elderly patients with significant pain (high risk for atypical presentations) 1

Remember that approximately one-third of patients presenting with abdominal pain have appendicitis, one-third have other documented pathology, and one-third never have a diagnosis established 1. A thorough, systematic examination is crucial for identifying those requiring urgent intervention.