1. Principles of Patient Assessment in EMS
By:
Bob Elling, MPA, EMT-P
&
Kirsten Elling, BS, EMT-P

2. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Chapter 15 – Focused History and Physical Exam of the Patient with Abdominal Pain
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Objectives
List and describe the three distinctive types of abdominal pain.
Describe specific information using OPQRST to ask the patient complaining of abdominal pain.
Describe specific information using SAMPLE pertinent to the patient complaining of abdominal pain.
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4. Objectives (continued)
Describe the steps to prepare a patient for physical examination of the abdomen.
List the normal and abnormal features to observe when examining the abdomen.
Describe the key feature of auscultation of bowel sounds for the EMS provider.
Describe the steps for light palpation, deep palpation and rebound tenderness of the abdomen.
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5. Objectives (continued)
Describe the normal percussion tones of the abdomen.
List the diagnostic tools the EMS provider may use during the examination of the patient with abdominal pain.
Describe why examination of the abdomen is different than examining other body parts.
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6. Objectives (continued)
Describe three reasons why the patient with severe abdominal pain may be difficult to assess.
List the most common causes of abdominal pain including intra-abdominal, extra-abdominal, metabolic and neurogenic causes.
List the causes of acute abdominal pain requiring surgery.
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7. Objectives (continued)
List the major gastrointestinal and genitourinary conditions the EMS provider may see in the prehospital setting.
Describe the clinical features associated with the major GI and GU conditions.
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Introduction
Abdominal pain has many etiologies.
Many causes are not life-threatening and require only supportive care.
Life-threatening causes include:
AMI
Ectopic pregnancy
Acute appendicitis
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Introduction
The EMS provider should know clinical signs and symptoms and history taking unique to the patient with acute abdominal pain.
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10. Types of Abdominal Pain
Visceral – pain is caused by stretching of nerve fibers surrounding the organs.
Often poorly localized, diffuse and difficult to describe
Patient may complain of feeling crampy or gaseous
Patient may be guarding
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11. Types of Abdominal Pain (Continued)
Somatic – pain is caused by irritation of nerve fibers in the parietal peritoneum.
Pain is usually more localized
Described as sharp and constant
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12. Types of Abdominal Pain (continued)
Referred – pain that originates from one area of the body and is also sensed in another area.
There are several referral patterns associated with abdominal pain
Review Table 15-1
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Focused History
Be alert for clues to extra-abdominal causes of abdominal pain such as AMI and ectopic pregnancy.
Use OPQRST to elaborate on the chief complaint of abdominal pain.
Obtain a SAMPLE History on the patient.
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Physical Exam
Assess MS-ABCs, skin CTC, and signs of poor perfusion.
Assess patient’s level of distress as mild, moderate, or severe.
Abdominal distress usually produces autonomic nervous system reactions such as tachycardia and diaphoresis.
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Physical Exam
After the IA, focus the exam on the CC.
Assess each of the 4 quadrants.
Examine in this order: observe, auscultate, palpate, percuss.
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Observation
Note the following:
Symmetry
Skin tone
Masses
Bulges
Surgical scars
Rashes
Lesions
Transderm patches
Colostomy attachments
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17. Observation (continued)
Cullen’s sign – periumbilical eccymosis.
Presacral edema – associated with limited mobility and cardiac history.
Pulsations from the abdominal aorta are normal in thin persons.
Pulsations from masses/bulges are abnormal.
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18. Observation (continued)
Ask the patient about bloating/distension as it is not always obvious.
Scaphoid abdomen – sinking, concave shape associated with dehydration or malnutrition.
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Auscultation
Listen for the presence or absence of bowel sounds (normal 5 to 30 times a minute).
The most significant finding is the absence of bowel sounds (obstruction, inflammation of peritonittis).
Assess only when time permits (2-5 minutes).
Auscultate prior to palpation.
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Palpation
Warm hands and position the patient on the back.
A normal abdomen should be soft, non-tender, without masses/bulges.
Note tenderness, temperature, guarding, and presence of abnormal structures.
Three types of palpation:
Light
Deep
Rebound
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21. Palpation (continued)
Light palpation – using one hand to palpate approx. 1 cm in depth.
Deep palpation – using one or two hands, palpate 2-3 inches. (Do not perform deep palpation on masses).
Rebound tenderness – palpate one quadrant, then quickly remove hand. If the patient has pain with the release of pressure this is call rebound tenderness (associated with peritoneal irritation).
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Percussion
Performed by touching and tapping the fingertips on various body parts.
Determines size, position, and consistency of underlying structures.
Most frequently used over the chest and abdomen.
Not routinely performed in the prehospital setting due to time constraints.
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Diagnostic Tools
Consider obtaining the following on the patient with abdominal complaints:
ECG
Pulse oximetry reading
Temperature
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24. Features of Abdominal Pain
The location of pain is not always an accurate indication of the cause of the pain.
Suspect any pain above the umbilicus as cardiac until proven otherwise.
In females of child bearing age suspect ectopic pregnancy until proven otherwise.
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25. Features of Abdominal Pain
Consider the many possible referral patterns of pain.
Patients with severe pain may be difficult to assess.
Consider skin signs (CTC)
Level of distress
Position of comfort/ guarding
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26. Common Causes of Abdominal Pain
Specific diagnosis is difficult, even in the ED.
Numerous causes:
Intra-abdominal
Extra-abdominal
Metabolic
Neurologic
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27. Common Causes of Abdominal Pain
Inflammation, obstruction, infection, hemorrhage or any combination.
Conditions that require surgical intervention include:
Appendicitis, ectopic pregnancy, tumors
Cholecystitis, perforated peptic ulcer or viscus
Dissecting and rupture aneurysm or bowel infarction
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Conclusion
The focused physical exam of the patient with abdominal pain should be performed quickly to identify any significant injury, potential hemorrhage or indications of a possible surgical abdomen.
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Conclusion
Specific diagnosis is not the objective.
Obtain a FH and PE, consider life-threatening conditions such as AMI and ectopic pregnancy early!
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