Treating Upper Abdominal Pain

Patient: 66-Year-Old Black / African-American Female With Complaint of Sudden Onset of Mid Upper Epigastric Pain

Pertinent PMH

During the initial medical exam, it is critical to gauge the severity of the pain. The healthcare practitioner should inquire as to the presence of previous medical conditions such as colitis, Crohn's disease, and IBS which could be the cause of the sudden onset. In the instance of abdominal pain, the provider should determine the precise location of pain as much as is possible even though referent pain is often an issue. Even though the pain is located in the upper abdominal quadrant, greater specificity is needed to eliminate possible causes. For example, "pain in the patient's right-upper abdomen can indicate gallstones or inflammation" or "duodenal ulcers, acute pancreatitis, acute cholecystitis, and acute hepatitis" (Lipman 2009; Karnath & Mileski, 2002, p. 46). In contrast, pain in the right mid-upper abdomen, may indicate "stomach or pancreas problem" or "gastritis, gastric ulcer, acute pancreatitis, and splenic infarct or rupture" (Lipman 2009; Karnath & Mileski, 2002, p. 46). The provider should also inquire as to any medications the patient may have taken and apparently unrelated but significant conditions such as heart disease.

ROS

The provider should ask about what foods the patient has ingested recently; when the pain started to occur, if the pain is steady and constant or inconsistent; if this type of pain is a recurring problem; dietary habits; and changes in the patient's routine. The provider should also ask about any other presenting symptoms such as edema, dizziness, shortness of breath. The provider should have the patient quantify the pain on a scale from 1-10.

HEENT

When presenting abdominal pain, palpation of the abdomen is the usual first step. But it is advised that "prior to palpation of the abdomen," the provider should "ask the patient to point with one finger to where the pain is greatest. This will assist you in determining whether the pain is localized or diffuse" (Mistovich, Krost, & Limmer, 2008). Palpitation, done correctly, can be an extremely useful source of information. "In patients with cholecystitis [inflammation of the gallbladder], Murphy's sign can be elicited by having the patient take a deep breath while the right subcostal area is palpated" (Karnath & Mileski, 2002, p. 46).