Pain in the gut

Does a late-night page about abdominal pain tie your stomach up in knots? Take 10 minutes to work through this module and leverage your AMBOSS resources!

You’re an intern cross-covering overnight for the general internal medicine service. You've just scored a premium spot in the back of the nurses' station and are hoping to knock out some notes. For the moment, it's unusually quiet...so quiet that the loudest sound in the room is your borborygmi. That late-night tuna melt in the cafeteria might not have been such a good idea.

But peace is fleeting. Just as you start typing, your pager goes off, vibrating louder than your gut.

Click the pager icon to reveal the message.

Your stomach turns—whether from the tuna melt or the page, it’s hard to say. You sigh and think, It always comes in waves.

Question: How urgently should you assess the patient?

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

• Right now
• Once your stomach settles a little
• Once you’ve caught up on your notes

Good decision going now. Assuming your stomach lets you forget about that tuna melt, you have a minute to collect your thoughts while taking the elevator to the patient's floor.

Signout sheet review

Your signout sheet can be your best friend. That folded piece of paper is more than a checklist—it’s a treasure map packed with clinical clues. Even the most “routine” details can hint at something more. Consider what each of the following details might be telling you, then click on the explanation bubbles for more information.

• Age: 69 years
• Code status: FULL CODE
• Admission diagnosis: AECOPD
• Past medical history: COPD, mild hypertension
• Hospital course: improving on IV corticosteroids, tolerating a full diet, planned for discharge
• Allergies: cephalosporins
• Recent laboratory results: elevated WBC (attributed to steroids)

Question: What red flags should you be looking for?

Recognizing a bad situation early and calling for help can save a life. So, even before you see the patient, you can review the red flags that indicate an increased risk for a life-threatening cause of abdominal pain. Think of at least one red flag for each category, then click on the explanation bubbles for more information.

• Risk factors
• Abnormal vital signs
• Pain characteristics
• Accompanying symptoms
• Examination findings

In older adults or immunocompromised patients, red flags can be blunted or absent.

You step off the elevator only to be hit by the buttery scent of microwave popcorn. You suppress a gag and quickly find the nurses' station. The nurse who paged you gives you a quick wave.

“I had her yesterday,” the nurse says. “She was short of breath in the evening, then was borderline all night, but she turned the corner today. They were planning to discharge her tomorrow morning.” The nurse shrugs. “Then, right after dinner, she started moaning and clutching her belly. I guess it's new because she never mentioned abdominal pain yesterday.”

Question: What do you do next?

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

• Take a few minutes to review the EHR since the patient looks better than yesterday.
• Escape the smell of fake butter and go see the patient by yourself.
• Ask the nurse to come with you as you examine the patient.

You and the nurse arrive at the patient's room. From the doorway, you can see the patient lying on her back, very still, with knees flexed and eyes closed. She is wearing a nasal cannula. A blood-stained dressing covers her right forearm.

The portable bedside monitor isn’t connected to the patient, but the last vitals are still on the screen: heart rate 95 beats/minute, blood pressure 102/55 mm Hg, respiratory rate 28 breaths/minute, SpO₂ 95%. You glance around and notice a partially eaten dinner tray on the overbed table. The IV tubing is unhooked and dangling from the IV pole.

Question: What are your next steps?

Make your choices, then click on the explanation bubbles for more information.

• Perform an ABCDE survey.
• Start continuous monitoring and get a repeat blood pressure.
• Ask the nurse to reestablish IV access.
• Perform a focused examination.

Upper abdominal pain may result from diaphragmatic irritation due to intrathoracic pathology (e.g., pneumonia, pulmonary embolism).

Patients with abdominal pain should be closely monitored with continuous vitals and serial abdominal examinations until the underlying cause is identified and resolved.

You’ve done a great job with the initial approach, but like any bellyache, this could go one of two ways.

Question: Which clinical scenario would you like to explore?

Choose an option to continue the module:

• Option 1: Abdominal emergency
• Option 2: Abdominal pain with stable vital signs

Congratulations! You prioritized the care of your patient, and she's on the road again to recovery.

You succeeded in:

• Quickly triaging a potentially critically ill patient
• Identifying red flags for abdominal pain
• Knowing the initial management approach for acute abdominal pain
• Calling for surgical consultation immediately for signs of peritonitis and shock (Option 1)
• Performing additional diagnostics and serial abdominal examinations when appropriate (Option 2)
• Recognizing the importance of early supportive care, including pain control

Congratulations on completing this module. Hopefully you now feel more comfortable assessing a patient with acute abdominal pain!

Personal story from an AMBOSS clinician:

I was on weekend call for the surgical service at a community hospital. One of the older patients, who was on the vascular surgery service post-angiogram, had been scheduled for discharge that morning. However, a medication error—the wrong insulin dose—led the team to postpone discharge out of an abundance of caution.

Shortly after rounds, I was paged by the patient's nurse: The patient had a brief syncopal episode while on the toilet. When I arrived to evaluate him, he was sitting up, alert and oriented, and eating his breakfast. His vitals were normal, and his blood glucose was within normal limits. It felt reassuring.

Not long after, while I was seeing consults in the emergency department, I got another page: The same patient now had abdominal pain. Then, while I was still triaging who to see next, I got a third page: He had become tachycardic.

When I reexamined the patient, his belly was soft and nontender to palpation. His blood pressure was still borderline normal, but he was clearly more uncomfortable than before. Given the evolving picture, I checked in with my senior resident, and we ordered a contrast-enhanced CT of the abdomen and pelvis.

Radiology wasn't immediately available on weekends at our small community hospital, so we had to wait for on-call staff to come in. While we waited, I started IV fluids, kept the patient NPO, made sure his vital signs were continuously monitored, and performed frequent abdominal examinations.

To our surprise, when the CT scan was finally completed, it showed a contained rupture of an abdominal aortic aneurysm. We notified vascular surgery immediately, and the patient was transferred to the main campus for urgent intervention. By the time he left our unit, a pulsatile mass was clearly visible on his abdomen—something that hadn’t been there just hours earlier.

Fortunately, multiple things were done well in this case. The nurse called every time something changed, and those early observations made a difference. When I wasn't sure what was going on, I looped in the senior resident, and we didn't anchor onto the insulin dosing error; instead, we kept asking questions. In this older patient with a vascular history and recent procedure, we took the new abdominal pain seriously, even when his vital signs could have been rationalized as “okay.” Finally, when there was a delay on imaging, we didn't wait passively; we started fluids, made the patient NPO, and monitored him closely.

The lesson I learned: Abdominal pain in older adults is never benign until you prove it. New pain and a change in vitals should prompt you to stop and reassess—pain plus tachycardia could be hidden hemorrhage! Finally, saying “something feels off” is never the wrong move; it’s a sign of clinical maturity, not weakness.