notes of JP Ferrara MD http://members.tripod.com/~uncljoedoc/index.html                             
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			    Recognition of the Acute Abdomen

Examination of the Abdomen
	observation
		general condition
			Peritonitis refers to pus in the abdomen. 
			A patient with peritionitis may appear quiet 
			and afraid to make sudden movements. An agitated 
			and mobile patient with abdominal pain may 
			have colicky pain. Gallbladder stone, intestinal 
			obstruction, or renal stone can cause colicky pain. 
		distention
			Abdominal distention can be due to fluid in the 
			abdomen or bowel obstruction.
		peristalsis
			Sometimes it is possible to see the peristaltic 
			waves through the abdominal wall. This may be a 
			sign of intestinal obstruction.           
	palpation
		rigidity
			With pus in the abdomen, the peritoneum is inflamed. 
			When this occurs, any attempt to press on the abdomen 
			will result in a response of abdominal wall rigidity.  
		guarding
			Guarding refers to an involuntary response of 
			the abdominal wall muscles in the presence of 
			peritonitis. The abdomen tenses up when palpated 
			when there is pus in the abdomen.
	auscultation
		bowel sounds
			increased
				Increased bowel sounds may be a sign of 
				intestinal obstruction. The bowel is working 
				overtime in order to try to get passed the 
				obstruction. Bowel sound are also increased                                      
				in gastroenteritis.
			decreased
				Decreased or absent bowel sound can be a 
				sign of either peritonitis or bowel death.             
		bruits
			Bruits are rhythmic sounds of blood flow which are 
			increased and may be due to a splenic artery or 
			aortic aneurysm.  
Some Diagnostic Considerations

	Hard to recognize conditions such as poisoning, theophylline 
	toxicity, diabetic ketoacidosis often present as abdominal pain.

	right upper quadrant
		gallbladder
			A gallbladder stone or gall bladder infection 
			will cause right upper quadrant pain and guarding.

		pancreas
			The pancreas spans the upper abdomen and so 
			pancreatitis can cause tenderness and guarding 
			in the right and left upper quadrants or dead center. 
			Pancreatis also causes nausea vomiting and pain 
			radiation to the midback. 
		liver
			Liver disease gives right upper quadrant signs. 
			The liver is in the right upper quadrant for 
			the most part.
		renal
			The right kidney is in the right upper quadrant 
			and may refer pain to this quadrant with infection 
			or stone. There usually is flank pain as well.

	left upper quadrant
		stomach
			A perforated stomach or duodenal ulcer will give 
			intense pain and guarding and rigidity on abdominal 
			exam. This may start in the mid or left upper 
			abdomen.
		spleen
			The spleen is well up in the left upper quadrant. 
			Therefore an enlarged spleen, or one that is 
			injured will be appreciated in the left upper 
			quadrant.
		left renal
			The left kidney may give symptoms and signs in 
			the left upper quadrant.

	right lower quadrant
		appendix
			Appendicitis gives right lower quadrant pain and 
			guarding. This often begins however as diffuse or 
			upper mid abdominal pain. 
		ectopic pregnancy
			An early tubal (poorly positioned) pregnancy will 
			go on to rupture and hemorrhage and must be 
			recognized. It will usually give significant pain 
			and guarding in the lower quadrant on the 
			affected side.
		renal colic
			ureter stones can give colicky lower quadrant pain 
			on the affected side.

	left lower quadrant
		diverticulitis
			Diverticuli are small sacs that form on the large 
			bowel wall most often on the left side especially 
			in middle aged and older patients. These can 
			become blocked, infected and may perforate.
			This is an important cause of left lower quadrant 
			pain, and guarding.
		ectopic pregnancy
			as above
		renal colic
			as above

Labs to get.
	CBC, Liver function tests, Amylase and lipase for pancreatitis, 
	EKG, abdominal  xray series consisting of Chest xray and 
	Flat Plate and upright of abdomen. 
	Blood cultures with fever and serious findings on physical exam. 
	Serum HCG. U/A.

Do's and Don'ts in recognizing abdominal emergencies

Do...
	Look at the "whole patient". 
	A patient with abdominal pain who appears pale or  
	sweaty or weak often has life threatening disease.

	Look for absent bowel sound, guarding and rigidity. 
	These are signs of life threatening peritonitis.

	Look for abdominal aortic aneurysm, ectopic pregnancy, 
	peritonitis, heart attack in patients with abdominal pain. 
	These are conditions which progress rapidly and are life threatening.

Don't...
	...allow the patient to wait. 
	A patient with peritonitis for example can go rapidly downhill.
	
	...overlook abnormal vital signs. 
	Rapid pulse, fever and rapid breathing are clues to   
	severity of abdominal illness.

	...rely on patient history alone. 
	A female patient for example who denies sexual activity  
	or says she has her period still must be worked up for an ectopic.