What is the appropriate history and physical examination for a patient presenting with abdominal symptoms and suspected pancreatitis?

History and Physical Examination for Suspected Pancreatitis

The appropriate history and physical examination for a patient with suspected pancreatitis should focus on identifying characteristic abdominal pain, risk factors, and physical findings that can help establish diagnosis and predict severity. 1, 2

History Taking

Pain Characteristics

• Assess for typical epigastric or upper abdominal pain that often radiates to the back 1, 2
• Document pain onset (sudden vs. gradual), intensity, character (dull, sharp, boring), and any radiation pattern 2
• Note any aggravating or alleviating factors, particularly relationship to meals 2
• Document duration of symptoms and any similar previous episodes 3

Associated Symptoms

• Inquire about nausea, vomiting, anorexia, and fever 2
• Document any changes in bowel habits (diarrhea, steatorrhea) that might suggest exocrine insufficiency 4
• Ask about recent weight loss, which could indicate chronic disease or malignancy 3

Etiological Risk Factors

• Obtain detailed alcohol consumption history (quantity, frequency, duration, and last drink) 4
• Document complete medication history to identify drugs associated with pancreatitis 4
• Assess for history of gallstones, recent ERCP, or abdominal trauma 4, 2
• Inquire about smoking history (pack-years) as it's a significant independent risk factor 4
• Document family history of pancreatitis or pancreatic disorders to identify possible hereditary causes 4

Previous Episodes and Complications

• Ask about previous episodes of pancreatitis, their severity, and treatments received 3, 5
• Document any known complications from previous episodes (pseudocysts, necrosis) 5
• Inquire about previous imaging studies or interventions 3

Physical Examination

General Assessment

• Document vital signs with particular attention to tachycardia, hypotension, fever, or tachypnea which may indicate severe disease or complications 2
• Assess overall appearance for signs of distress, dehydration, or jaundice 2

Abdominal Examination

• Inspect for abdominal distension, visible peristalsis, or surgical scars 2, 6
• Look for ecchymoses such as Cullen's sign (periumbilical) or Grey-Turner's sign (flank), which suggest severe hemorrhagic pancreatitis 2
• Perform careful palpation to locate areas of tenderness, with special attention to epigastric region 2
• Assess for guarding, rebound tenderness, or rigidity that might indicate peritoneal inflammation 2, 7
• Document presence or absence of palpable masses that could suggest pseudocyst or pancreatic tumor 3
• Evaluate for hepatomegaly or splenomegaly 6
• Perform percussion to assess for ascites or tympany 6
• Auscultate for bowel sounds, which may be diminished or absent in severe pancreatitis 2

Other Systems

• Examine for signs of systemic complications such as pleural effusions (decreased breath sounds at lung bases) 8
• Assess for signs of chronic disease such as muscle wasting or temporal wasting 9
• Check for peripheral edema which might indicate hypoalbuminemia from chronic disease 9

Initial Laboratory and Imaging Considerations

• Serum lipase is the preferred diagnostic marker over amylase due to higher specificity and longer elevation duration 1, 2
• Liver function tests, triglycerides, and calcium levels should be obtained to help determine etiology 1, 2
• Abdominal ultrasonography should be performed early to evaluate for gallstones 1, 2
• CT scanning should be used selectively based on clinical features and is most valuable after 72 hours from symptom onset 1, 2

Special Considerations

• For recurrent episodes, a more thorough evaluation for anatomic variants (pancreas divisum) or occult malignancy may be needed 3
• In patients over 40 years with unexplained pancreatitis, evaluation for underlying pancreatic malignancy is essential 1
• Patients with predicted severe disease require more intensive monitoring for organ failure and local complications 3, 1