What is the recommended assessment template for a patient presenting with abdominal pain, considering their demographic information, medical history, and associated symptoms?

Assessment Template for Abdominal Pain

A structured assessment template for abdominal pain should prioritize pain location as the primary organizing principle, followed by systematic evaluation of red flag features, targeted physical examination findings, and location-specific laboratory and imaging studies to guide diagnosis and management. 1, 2

I. Initial Triage and Red Flag Assessment

Vital Signs Assessment

• Document heart rate carefully - tachycardia is the most sensitive early warning sign of surgical complications and should trigger urgent investigation even before other symptoms develop 2
• Evaluate for fever, hypotension, or tachypnea which indicate infection, bleeding, or sepsis 2
• The combination of fever, tachycardia, and tachypnea predicts serious complications including anastomotic leak, perforation, or sepsis 2

Critical Red Flags Requiring Urgent Evaluation

• Pain out of proportion to physical examination findings - assume acute mesenteric ischemia until proven otherwise 2, 3
• Abrupt or instantaneous onset of severe pain suggests vascular catastrophe (aortic dissection or mesenteric ischemia) 2
• Peritoneal signs (rigid abdomen, rebound tenderness) indicate perforation or ischemia 3
• Hemodynamic instability suggests bleeding or sepsis 3
• Syncope with abdominal pain warrants evaluation for pericardial tamponade or aortic dissection 2

II. Pain Characteristics Documentation

Location-Based Classification

• Right upper quadrant: Consider acute cholecystitis, hepatobiliary pathology, choledocholithiasis, cholangitis 3
• Right lower quadrant: Appendicitis is the most critical diagnosis to exclude; also consider ectopic pregnancy in women of reproductive age 3
• Left lower quadrant: Diverticulitis in older adults, sigmoid volvulus with chronic constipation history 3
• Epigastric/diffuse: Peptic ulcer disease, gastritis, acute pancreatitis, mesenteric ischemia 3
• Nonlocalized or diffuse pain requires broader evaluation with CT imaging 2

Pain Quality and Onset

• Ripping, tearing, stabbing, or sharp quality suggests aortic dissection 2
• Colicky pain indicates bowel obstruction as the bowel attempts to overcome occlusion 2
• Severe intensity pain warrants urgent evaluation 2

III. Targeted History Elements

Gastrointestinal Symptoms

• Last bowel movement and passage of gas - has 85% sensitivity and 78% specificity for predicting adhesive small bowel obstruction in patients with prior abdominal surgery 2
• Vomiting occurs earlier and more prominently in small bowel obstruction versus large bowel obstruction 2
• The triad of abdominal pain, constipation, and vomiting suggests sigmoid volvulus 2
• Diarrhea may precede other symptoms by several days 2
• Approximately 25% of acute mesenteric ischemia patients have occult blood in stool 2

Past Medical History - Critical Elements

• Any prior laparotomy makes adhesive obstruction the leading diagnosis (55-75% of small bowel obstructions) 2, 3
• Atrial fibrillation is present in nearly 50% of patients with embolic acute mesenteric ischemia 2
• History of prior arterial embolus occurs in approximately one-third of embolic acute mesenteric ischemia patients 2
• Previous diverticulitis episodes suggest diverticular stenosis 2
• Chronic constipation history raises suspicion for dolichosigmoid and volvulus 2
• Cardiovascular disease with acute abdominal pain should raise suspicion for acute intestinal ischemia 2

Medication History

• Oral contraceptives and estrogen use predispose to mesenteric venous thrombosis 2
• Psychotropic medications cause chronic constipation predisposing to volvulus, particularly in elderly institutionalized patients 2
• Use of vasoconstrictive agents may precipitate non-occlusive mesenteric ischemia 2

Special Population Considerations

• Women of reproductive age: Document last menstrual period and consider ectopic pregnancy, ovarian torsion, pelvic inflammatory disease 2, 3
• Elderly patients: Have higher likelihood of malignancy, diverticulitis, and vascular causes; may present with atypical symptoms and normal laboratory tests 4, 2, 3
• Post-bariatric surgery patients: Often present with atypical symptoms; tachycardia is the most critical warning sign; classic peritoneal signs are often absent 2
• Immunocompromised patients: Typical signs of abdominal sepsis may be masked, diagnosis may be delayed, and associated with high mortality rate 4

IV. Physical Examination - Key Findings

Inspection

• Asymmetric gaseous distention with emptiness of the left iliac fossa is pathognomonic for sigmoid volvulus 2
• Abdominal distension with vomiting indicates bowel obstruction 3
• Examine all hernia orifices and surgical scars - overlooking these can miss incarcerated hernias 3

Palpation

• Document presence or absence of peritoneal signs (rebound tenderness, guarding, rigidity) 3
• Positive Murphy's sign (pain when pressing the right upper quadrant) suggests cholecystitis 2
• Empty rectum on digital examination is classic for sigmoid volvulus 2

Critical Caveat

• The absence of peritonitis on examination does not exclude bowel ischemia - patients with sigmoid volvulus often lack peritoneal signs despite having established ischemia due to chronic distension masking the examination 2

V. Laboratory Evaluation

Mandatory Initial Tests

• Complete blood count (CBC) to assess for leukocytosis indicating infection or inflammation 1, 2
• Comprehensive metabolic panel (CMP) including liver function tests to evaluate hepatobiliary pathology and organ function 1
• Urinalysis to evaluate for urinary tract infection or nephrolithiasis 1
• Serum lipase (more specific than amylase for diagnosing pancreatitis) 1
• Beta-human chorionic gonadotropin (β-hCG) testing is mandatory in all women of reproductive age before imaging to rule out pregnancy-related conditions including ectopic pregnancy 1, 2, 3

Additional Tests Based on Clinical Suspicion

• High C-reactive protein has superior sensitivity and specificity compared to white blood cell count for ruling in surgical disease, though normal CRP does not exclude complications 2
• Elevated lactate suggests ischemia or sepsis, but normal levels do not exclude internal herniation or early ischemia 2
• Procalcitonin is helpful for assessing inflammatory response in suspected sepsis 2
• Blood cultures should be considered if sepsis is suspected, especially with fever and abdominal pain 1
• D-dimer and lactate may be helpful if mesenteric ischemia is suspected, though they lack specificity 1, 2

Common Pitfall to Avoid

• Over-relying on normal laboratory values early in disease can lead to missed diagnoses - many laboratory tests are nonspecific and may be normal despite serious infection, especially in elderly patients 4, 2, 3

VI. Imaging Studies - Location-Based Algorithm

Right Upper Quadrant Pain

• Abdominal ultrasound is the initial imaging test of choice for evaluating acute cholecystitis and hepatobiliary pathologies 1, 2, 3

Right Lower Quadrant Pain

• CT of the abdomen and pelvis with contrast is the most appropriate initial imaging method for suspected appendicitis 2, 3
• Consider ultrasound as initial imaging before proceeding to CT to minimize radiation exposure 2

Left Lower Quadrant Pain

• CT of the abdomen and pelvis with contrast is recommended, especially for suspected diverticulitis 2

Pelvic Pain

• CT of the abdomen and pelvis with contrast is the most appropriate initial imaging method 2

Nonspecific/Diffuse Abdominal Pain

• CT of the abdomen and pelvis with IV contrast is the preferred imaging option, especially if there is fever or suspicion of serious illness 4, 2, 3
• CT changes the primary diagnosis in 51% of cases and alters the admission decision in 25% of cases 3

Suspected Specific Conditions

• Kidney stones: Non-contrast CT of the abdomen and pelvis 2
• Bowel obstruction: CT of the abdomen and pelvis with contrast 2
• Mesenteric ischemia: CT angiography of the abdomen 2

Important Imaging Considerations

• Conventional radiography has limited diagnostic value in most patients with abdominal pain and should not be routinely ordered 1, 2
• Plain radiographs have low sensitivity for sources of abdominal pain and fever or abscess 4
• Avoid overuse of CT scans to minimize ionizing radiation exposure, especially in young patients 2
• Consider extra-abdominal causes such as pneumonia which can cause referred abdominal pain 3

VII. Documentation of Differential Diagnosis by Mechanism

Obstructive Causes

• Adhesions account for 55-75% of small bowel obstructions 2, 3
• Hernias cause 15-25% of small bowel obstructions 3
• Colorectal cancer causes 60% of large bowel obstructions 3
• Volvulus causes 15-20% of large bowel obstructions 3

Inflammatory/Infectious Causes

• Appendicitis (frequency of 15.9-28.1% of cases requiring surgery) 2
• Cholecystitis, diverticulitis, pancreatitis, pelvic inflammatory disease 3

Vascular Causes

• Mesenteric ischemia (arterial or venous thrombosis) 3
• The triad of abdominal pain, fever, and hemocult-positive stools occurs in approximately one-third of acute mesenteric ischemia patients 2

Other Considerations

• Colitis and inflammatory bowel disease 3
• Benign adnexal mass and pelvic congestion syndrome in women 3