Does the patient have a surgical abdomen?

• Gastric outlet obstruction
• Small or large bowel obstruction
• Appendicitis
• Ruptured Viscus
• Intestinal ischemia
• Biliary colic

Does the patient have a "medical" abdomen?

• Constipation
• Peptic ulcer disease/dyspepsia
• Pancreatitis
• Gastroenteritis
• Paralytic ileus
• Inferior wall MI
• Acute urinary retention
• Kidney stone
• Medications (opioids, NSAIDS, EtOH, chemotherapy, others)

• Prior history of illnesses listed above?
• When was last bowel movement?
• Any medications that could be causing symptoms?

Vital signs

• Is the patient writhing (colicky=obstruction of viscus) or lying flat (peritonitis)?
• Any suggestion of an acute inflammatory process or abdominal catastrophe? (hypotension, fever, tachycardia).

Abdomen:

• Any suggestion of peritonitis (involuntary guarding, rigidity, rebound tenderness) or obstruction (tympanic, hyperactive bowel sounds)?
• Distended bladder?
• Rectal examination for fecal impaction, lateral tenderness, mass, blood in stool.

Female genitalia

• PID or ovarian cyst?

• Review chart. Acute abdominal pain in the elderly or diabetic is worrisome for a surgical cause.

• Decide if you are dealing with a potential acute abdomen. If yes, call a general surgery consult ASAP.

• Consider the following options, based on your assessment:

Flat & upright KUB and CXR to rule out obstruction, fecal impaction, and free air under diaphragm.

Trial of Maalox 30 cc for dyspepsia, PUD. Rapid relief of symptoms is typical.

ECG to r/o IWMI.

Enemas/disimpaction.

• Compazine 10 mg q 4-6 po or 25 mg pr for nausea.