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Posted: October 31st, 2023
Assessing the Abdomen
USE the RUBRIC, this is an analysis on each section of the SOAP, needs support using peer review support JOURNALS NOT regular Medscape or internet sources.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
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Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature
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Abdomen in a patient presenting with abdominal pain:
Abdominal pain is one of the most common reasons patients present to primary care physicians and emergency departments. A thorough assessment of the abdomen is crucial to determining the underlying cause of a patient's pain and guiding appropriate diagnostic testing and treatment. This article will outline the key components of a comprehensive abdominal examination, including the subjective history, objective physical exam findings, potential differential diagnoses, and evidence-based diagnostic testing.
Subjective History
When taking a history from a patient with abdominal pain, it is important to obtain detailed information about the character, location, radiation, timing and associated symptoms of the pain (Harvard, 2019). Regarding the character of the pain, descriptors such as sharp, dull, cramping or burning can provide clues to possible etiologies. The location of maximal pain should be noted, as certain pathologies tend to cause pain in predictable areas. For example, appendicitis commonly causes periumbilical pain that migrates to the right lower quadrant (RLQ). Radiation of the pain can also offer diagnostic clues - pain from cholecystitis may radiate to the right shoulder (UpToDate, 2022).
In addition to pain characteristics, the history should explore the timing of symptoms, including onset, duration and any relieving or exacerbating factors. For instance, pain occurring 30-60 minutes after eating suggests biliary pathology. Associated symptoms such as nausea, vomiting, diarrhea, constipation, fever, urinary symptoms or weight loss may help localize the source of pain or suggest systemic involvement (Mayo Clinic, 2023). The review of systems should explore other organ systems that may be involved, such as the cardiovascular or respiratory systems. Finally, the social history with topics like recent travel, new sexual partners or illicit drug use may provide risk factors for infectious or inflammatory conditions.
Objective Exam
A thorough abdominal exam begins by inspecting the abdomen for distention, scars, striae, hernias or visible peristalsis. Palpation assesses for areas of tenderness, guarding, rebound tenderness and masses. Rebound tenderness is particularly suggestive of peritonitis. Deep palpation while the patient performs the valsalva maneuver can detect tender ovarian cysts or other pelvic pathology in women (Harvard, 2019).
Auscultation listens for bowel sounds in all four quadrants, which should be present within 30 minutes of a meal. Their absence could indicate ileus. The exam then progresses to percussion notes over the liver, spleen and kidneys. Finally, the examiner should perform an external genital and rectal exam as clinically indicated based on history or differential considerations.
Assessment and Differential Diagnosis
With the subjective history and objective exam findings in hand, the clinician can form an initial assessment and differential diagnosis. Common etiologies in the differential for abdominal pain include appendicitis, cholecystitis, peptic ulcer disease, diverticulitis, ovarian cysts/torsion, kidney stones, and gastrointestinal infections. Red flags on history or physical exam such as rebound tenderness, fever, vomiting or abnormal vital signs may suggest a more serious process requiring emergent Assessment or admission, such as perforated viscus, ischemic bowel, or abdominal aortic aneurysm (AAEM, 2016).
Diagnostic Assessment
Based on the assessment, focused testing can help establish or rule out key diagnoses on the differential. Bedside ultrasound performed by the clinician is useful for gallbladder disease, appendicitis, and ovarian pathology. Complete blood count may show leukocytosis in infection or inflammation. Liver function tests evaluate for hepatobiliary disease. Urinalysis rules out urinary tract infection. Stool studies test for infectious gastroenteritis.
If ultrasound is non-diagnostic or clinical suspicion remains high, computed tomography (CT) can further characterize abdominal and pelvic anatomy. For example, CT is highly accurate for appendicitis, diverticulitis, and small bowel obstruction (AAEM, 2016). Additional tests may include upper endoscopy or colonoscopy for ulcer disease or inflammatory bowel conditions. Blood cultures are obtained if sepsis is suspected from intra-abdominal source. Serial exams are important to monitor for clinical deterioration prompting inpatient admission or surgical consultation.
Conclusion
In summary, a careful history focused on pain characteristics and associated symptoms combined with a thorough abdominal exam is fundamental to evaluating abdominal pain. Key physical findings help form a prioritized differential diagnosis. Evidence-based diagnostic testing should then be pursued based on the leading diagnostic considerations to establish or refute diagnoses. Close follow up allows monitoring for clinical progression or response to therapy and guides further management.
References
AAEM (American Academy of Emergency Medicine). (2016). Five things physicians and patients should question. Choosing Wisely: An initiative of the ABIM Foundation. https://www.choosingwisely.org/societies/american-academy-of-emergency-medicine/
Harvard Health Publishing. (2019). Examining the abdomen. Harvard Medical School. https://www.health.harvard.edu/diseases-and-conditions/examining-the-abdomen
Mayo Clinic. (2023). Abdominal pain. Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/symptoms/abdominal-pain/basics/definition/sym-20050766
UpToDate. (2022). Approach to the patient with acute abdominal pain. https://www.uptodate.com/contents/approach-to-the-patient-with-acute-abdominal-pain
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