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CLINICAL PRESENTATION

..... History

A thoughtful history is important in obtaining an accurate diagnosis, but some specific historical elements can

lead to the rapid development of a targeted differential.

While keeping in mind that patients may have an atypical presentation of disease, the location of the pain, the

nature of the pain at onset, and how the pain behaves

since onset can help efficiently discriminate between different diagnostic considerations (Figure 26-1) . Pain that

is sudden and severe at onset is often associated with the

rupture of a blood vessel or hollow viscus ( eg, ruptured

AAA, perforated peptic ulcer), occlusion of a blood vessel or hollow viscus (eg, acute mesenteric ischemia, ure ­

teral colic), or gonadal torsion. In contrast, inflammatory

conditions tend to have a more insidious onset, as is seen

with appendicitis. Pain whose progression is colicky in

nature is suggestive of peristaltic activity in the setting of

an obstructed lumen ( eg, ureteral, biliary, intestinal

colic) .

The manner in which the pain radiates can suggest a

specific disease. Pain radiating to the back is often seen

with pancreatitis. Pain radiating to the right infrascapular

region is associated with biliary tract disorders. Pain that

radiates to the groin may indicate a ruptured aortic aneurysm or nephrolithiasis.

Associated symptoms involving the gastrointestinal,

genitourinary, and cardiopulmonary systems should be

obtained. The clinician, however, must keep a broad differential as the same symptom can be seen across many

disease processes. Nausea and vomiting are nonspecific

symptoms, although it is worthwhile noting the temporal

relationship between them. Surgical causes of abdominal

pain classically present with pain preceding vomiting,

whereas the reverse is often seen with medical etiologies.

The clinician must be cautious in using diarrhea as conclusive evidence of gastroenteritis, as it can also be seen with

appendicitis, diverticulitis, and partial small bowel o bstruction. Irritative voiding symptoms such as dysuria and frequency are suggestive of a urinary tract infection; however,

they can also be caused by appendicitis or pelvic abscess.

Hematuria should raise concern for nephrolithiasis or a

malignancy in the genitourinary tract. Vaginal bleeding

and discharge are important to elicit in assessing for ectopic pregnancy and pelvic inflammatory disease. As pneumonia, pulmonary embolism, and acute coronary

syndrome can all present with abdominal pain, the presence of cough, chest pain, and shortness of breath should

be ascertained.

A thorough past medical/surgical history, medications,

allergies, and social history should also be obtained. The

existence of known coronary artery or cerebrovascular

disease should raise suspicion for vascular disease of the

abdomen. Corticosteroids and immunosuppressants

should alert the clinician that the patient may not present

with typical symptoms or exam findings. Knowledge of

anticoagulants is critical in constructing the differential

diagnosis as well as making sure reversal is not needed

before any operative intervention. Heavy alcohol use raises

the possibility of hepatitis or pancreatitis.

..... Physical Examination

Vital signs should be readily noted, with tachycardia and/

or hypotension raising immediate concern for the presence

of shock.