What is the approach to evaluating a general adult patient with abdominal pain, considering demographic and medical history?

Review of Systems for Abdominal Pain

Mandatory Initial Assessment Elements

Begin by obtaining pregnancy status in all women of reproductive age before proceeding with any diagnostic workup or imaging, as this fundamentally alters the diagnostic approach and prevents unnecessary fetal radiation exposure. 1, 2, 3

Critical Historical Features to Elicit

Pain Characteristics:

• Location specificity is the most valuable starting point—right upper quadrant suggests hepatobiliary disease, right lower quadrant strongly indicates appendicitis, left lower quadrant points to diverticulitis, and diffuse pain requires broader evaluation 4, 2, 5
• Onset and duration distinguishes acute from chronic pain (chronic defined as >3 months), which fundamentally changes the diagnostic approach 6
• Quality and severity of pain, including whether it is constant, colicky, or intermittent 5, 7
• Radiation patterns—for example, right upper quadrant pain radiating to the shoulder suggests gallbladder pathology 4

Associated Symptoms:

• Fever raises concern for infection, abscess, or inflammatory processes and warrants blood cultures if sepsis is suspected 1, 2
• Nausea, vomiting, and anorexia—though anorexia has limited predictive value for appendicitis specifically 5
• Constipation and abdominal distension strongly suggest bowel obstruction 5
• Diarrhea may indicate infectious or inflammatory bowel disease 3
• Urinary symptoms to evaluate for urinary tract infection or nephrolithiasis 1

Red Flag Features:

• Hemodynamic instability (hypotension, tachycardia) requires immediate surgical consultation rather than extended workup 2
• Signs of peritonitis (guarding, rigidity, rebound tenderness) 7
• Jaundice suggests hepatobiliary pathology 4
• Gastrointestinal bleeding (hematemesis, melena, hematochezia) 7

Essential Past Medical and Social History

Medical History:

• Previous abdominal surgeries increase risk of adhesions and bowel obstruction 7
• History of any chronic pain condition is the strongest predictor of transition from acute to chronic pain 4
• Immunocompromised status requires more extensive workup 1
• Inflammatory bowel disease history, as pain may represent active inflammation, stricture, or functional overlay 4

Psychosocial Risk Factors for Chronic Pain Development:

• Early-life adversity, trauma, discrimination experiences, or poverty 4
• Poor coping styles including catastrophizing 4
• Pre-existing anxiety or depression 4
• Disability status, substance misuse history, or worker's compensation as these hasten conversion to chronic pain 4
• Availability of positive social support versus pain-reinforcing environmental factors 4

Physical Examination Priorities

Vital Signs:

• Temperature, heart rate, blood pressure to assess for sepsis or hemodynamic compromise 7

Abdominal Examination:

• Inspection for distension, surgical scars, or visible masses 8
• Auscultation for bowel sounds (absent in ileus/obstruction, high-pitched in early obstruction) 8
• Palpation for tenderness location, guarding, rigidity, rebound, and masses 5, 7
• Percussion for tympany (obstruction/ileus) versus dullness (ascites, mass) 8
• Special signs: McBurney's point tenderness (appendicitis), Murphy's sign (cholecystitis), psoas sign, obturator sign 5

Extra-abdominal Examination:

• Pelvic examination in women with lower abdominal pain to evaluate gynecologic causes 2
• Rectal examination for masses, tenderness, or occult blood 7
• Cardiovascular examination if considering mesenteric ischemia 1

Mandatory Laboratory Workup

Universal Initial Tests:

• Complete blood count to assess leukocytosis indicating infection or inflammation 1, 3
• Comprehensive metabolic panel including liver function tests (ALT, AST, alkaline phosphatase, bilirubin) to evaluate hepatobiliary pathology and organ function 1, 3
• Urinalysis for urinary tract infection or nephrolithiasis 1
• Serum lipase (more specific than amylase) for pancreatitis 1, 3
• Beta-hCG in all women of reproductive age—this is mandatory before imaging 1, 2, 3

Location-Specific Additional Tests:

• Right upper quadrant pain: Emphasize liver function tests and hepatobiliary markers 1
• Diffuse pain with concern for mesenteric ischemia: Add lactate and D-dimer, though these lack specificity 1, 2
• Fever with abdominal pain: Blood cultures if sepsis suspected 1

Critical Pitfalls to Avoid

• Never proceed with CT imaging in reproductive-age women without pregnancy testing, as this leads to delayed diagnosis of ectopic pregnancy and unnecessary fetal radiation exposure 1, 2, 3
• Do not order conventional radiography routinely—it has limited diagnostic value, rarely changes management, and should only be used for suspected bowel obstruction, perforated viscus, urinary calculi, or foreign bodies 4, 1, 2
• Do not assume normal initial labs exclude serious pathology in patients with high clinical suspicion—proceed to appropriate imaging 1
• In immunocompromised patients, maintain lower threshold for extensive workup as presentation may be atypical 1
• For chronic pain patients, recognize early that peripheral initiating factors differ from central maintaining factors—address fear of pain and central sensitization rather than repeatedly investigating resolved inflammation 4
• Do not delay imaging in clinically deteriorating patients while pursuing additional non-diagnostic tests 2

Distinguishing Acute from Chronic Pain

For pain >3 months duration, shift focus from organic pathology to functional disorders and central pain mechanisms once serious disease is excluded 6. Patients at highest risk of chronification include those with prior chronic pain, early-life trauma, catastrophizing, anxiety/depression, or negative prior pain experiences 4. In these cases, set expectations early that pain perception is real and multifactorial, and that addressing central maintaining factors (fear, central sensitization) through neuromodulation, brain-gut behavioral therapies, and low-dose tricyclic antidepressants or SNRIs is most critical 4. Repetitive testing after functional diagnosis is established is not recommended 6.