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“You can get past the dead end. You can break through the ceiling. I did and so have countless others.”

Clinical Pearl Wednesday #23

Have a patient with abdominal pain? Then you need to be on the lookout for peritoneal signs. If present, these mean the wall of the abdomen is inflamed. This warrants an urgent/emergent work up. If any of these are present, be concerned:

Is the pain worse with ambulation and movement?

Is the pain continuing to worsen or has it finally plateaued and is now constant?

Is the pain truly severe (8 out of 10 or more. I mean real pain, not dramatic pain).

Is the pain localized to one area of the abdomen?

Is there rebound, guarding, or rigidity on palpation?

Is there a positive Psoas sign?

Does the patient have significant painful facial expressions on palpation?

If these are present, you need to work up this patient immediately.

If these signs and symptoms are not present, then usually the abdominal pain is from a more benign etiology. Usually the abdomen is soft and does not illicit significant pain. The patient is typically comfortable during the exam. There are no peritoneal signs. This kind of presentation can be worked up in a more modest fashion.

Once you palpate multiple acute abdomens, you will understand what is serious and what is not. This comes with experience and developing that “intuition.”

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