Option 2: Abdominal pain with stable vital signs

The patient greets you when you say her name. She appears mildly uncomfortable but answers questions without difficulty. While you gather more history, the nurse repeats the vital signs: blood pressure 120/68 mm Hg, heart rate 85 beats/minute, respiratory rate 28 breaths/minute, SpO₂ 97%, and temperature 37.5° C.

Meanwhile, the patient tells you the following:

• The abdominal discomfort began a couple of days ago, around the same time her COPD symptoms worsened.
• Initially, the patient's breathing problems overshadowed the abdominal comfort, but the pain has gradually worsened and now is keeping her from sleeping.
• The pain is mostly in the LLQ, but she can “feel it everywhere.”
• The patient has a history of diverticulitis, and this pain feels “sort of similar” to prior episodes.
• The patient ate dinner despite the tuna tasting “funny,” and she has been drinking large amounts of water.
• The patient isn't nauseated but reports her stools have been “runnier than normal” today.
• The patient says her breathing is better now but “not perfect.”

You proceed to the physical examination, which shows:

• Heart: regular rhythm, no murmur
• Lungs: diminished breath sounds at the bases, equal bilaterally; scattered expiratory wheezes
• Abdomen: no visible distention; mild diffuse tenderness (most pronounced in the LLQ); no rebound tenderness; bowel sounds present but infrequent (2–3 per 30 seconds)
• Skin: dry, warm, pink; no IV access

Question: What should you do next?

Make your choice, then click on the explanation bubble to reveal the answer.

• Reassure the patient that she is fine; it was just the tuna.
• Obtain an immediate surgical consultation.
• Order additional diagnostics and perform serial examinations overnight.

Remain vigilant for disease progression in older or immunocompromised patients, as symptom intensity may not reflect disease severity.

Question: What should you do while you obtain further diagnostics?

Make your choices, then click on the explanation bubbles to reveal the answers.

• Make the patient NPO.
• Order a clear liquid diet.
• Ensure peripheral IV access.
• Give a fluid bolus.
• Order analgesics.
• Start empiric antibiotics.
• Perform serial abdominal examinations.

Question: Which diagnostic tests should you obtain now?

Make your choices, then click on the explanation bubbles to reveal the answers.

• CBC
• CMP
• CRP
• Amylase and lipase
• Urinalysis
• Coagulation studies
• Crossmatching
• Troponin
• Arterial blood gas
• Abdominal x-ray
• Abdominal CT

While this patient's age rules out pregnancy, obtain a urine pregnancy test in all patients who can become pregnant (regardless of reported contraceptive use) and who present with abdominal pain. An elevated β-hCG should prompt evaluation for intrauterine or ectopic pregnancy, both of which can manifest with abdominal pain and have significant management implications.

Activate the quiz tab and test your knowledge of the differential diagnosis of acute abdominal pain by region.

Differential diagnosis

If you haven't explored the other scenario yet, jump over to “Option 1: Abdominal emergency.” You can also return to the main module; see “Pain in the gut wrap-up.”