Patient Examination · VYS-BB-01
Abdominal Pain —
how to examine
from start to finish
Step by step: how each examination technique is performed, exactly what you’re looking for, how to correctly interpret the finding, and which red flags must stop you. This article is aimed primarily at paramedics early in their careers.
⚠ Load and go
In the presence of any red flag: secure IV access (2× large bore), monitor ECG + SpO₂ + BP, give O₂ if SpO₂ <94%, and transport urgently. Take the detailed history during transport, not instead of it.
Part 01
History-taking — how to ask and what to look for
With abdominal pain, history-taking gives you more than any other field examination. An experienced paramedic can estimate a working diagnosis even before touching the patient. Use the OPQRST structure — it’s a tool, not a checkbox.
| Letter | Term | How to ask and what to conclude | Red Flag answer |
|---|---|---|---|
| O | Onset |
“When did it start? Was it sudden — like something tore — or did it build up gradually?” Sudden onset = mechanical cause (perforation, torsion, dissection). Gradual over hours = inflammatory (appendicitis, cholecystitis). | Maximal pain from the first second → perforation, ruptured AAA, aortic dissection |
| P | Provocation |
“What makes the pain better or worse? Movement, breathing, food, position, bowel movements?” Relief in a side-lying position with knees drawn up = pancreatitis. Worse with movement = peritonitis. Worse after fatty food = gallbladder. | Worse with every movement of the abdomen, even a slight jolt = peritoneal irritation |
| Q | Quality |
“Describe the pain to me — is it more crampy, throbbing, burning, or a sharp constant pain?” Colicky (comes and goes) = hollow organs (bowel obstruction, gallbladder, ureter). Constant sharp = inflammation or ischemia. Tearing/throbbing = vascular. | Tearing/throbbing pain + mass = AAA; pain out of proportion to the finding = mesenteric ischemia |
| R | Radiation |
“Does the pain spread anywhere else — to the back, shoulder, groin?” To the right shoulder = diaphragmatic irritation (gallbladder, blood under the diaphragm). Straight to the back = pancreas or aorta. To the groin/ovaries = ureterolithiasis or hernia. | Pain radiating to the back + BP instability = AAA or aortic dissection — urgent transport |
| S | Severity |
“On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain of your life — where are you now? And what was it at the start?” The trend matters: VAS 8→4 = improving. VAS 4→9 = worsening or a complication developing. | VAS 10/10 at onset or rising VAS = urgent; in elderly patients even VAS 4 can mean perforation! |
| T | Time / course |
“How long has this been going on? Is it continuous, or does it alternate between better and worse? Have you had similar pain before?” Recurring colic = chronic pathology (gallstones, IBD). First time ever = unknown cause, take a more cautious approach. | First-ever pain like this + hemodynamic instability = always urgent regardless of character |
ℹ Clinical pearl
A patient lying absolutely still, afraid to move, should concern you more than one writhing in pain. Stillness = peritoneal irritation. Writhing = colic (hollow organs — not as surgically acute).
⚡ Don’t forget to ask
LMP (last menstrual period) in every woman of reproductive age — ectopic pregnancy kills fast and presents as “just” lower abdominal pain. Past surgeries — incisional hernias, adhesions, ileus. Medications — NSAIDs/corticosteroids mask peritonitis. Diabetes — DKA presents as an acute abdomen.
Part 02
Physical examination — sequence and technique
Physical examination of the abdomen has a precise order: inspection → auscultation → percussion → palpation. This order isn’t accidental — palpation stimulates peristalsis and would distort auscultation. Each step gives you a different type of information.
Inspection
You look — the patient doesn’t have to move, you cause no pain
Procedure — how to do it
1
Position and behavior of the patient. Observe before you start asking questions. Are they lying still? Writhing? In a side-lying position with knees drawn up? Stillness = peritoneal irritation. Writhing = colic.
2
Expose the abdomen — all of it. From the ribs to the inguinal ligaments. Ask the patient to lift their shirt. Don’t sit an unstable patient up. You see nothing if the abdomen is covered — mistake #1 for beginners.
3
Shape and symmetry of the abdomen. Is it flat, scaphoid, or distended? Is the distension diffuse (ileus, ascites) or localized (mass, hernia)? Asymmetric distension in one quadrant = a mass or localized ileus.
4
Skin and visible changes. Jaundice (yellowing of the sclera + skin = biliary obstruction), Grey Turner’s sign (flank ecchymosis = retroperitoneal bleeding, pancreatitis), Cullen’s sign (periumbilical ecchymosis = hemoperitoneum). Surgical scars. Grey Turner and Cullen are late-appearing signs — their absence doesn’t rule out bleeding.
5
Visible peristalsis or pulsation. Wave-like movements under the skin = small bowel obstruction (in thin patients). Visible pulsation in the epigastrium = can be normal in thin patients, or AAA in the obese/elderly. Visible pulsation + abdominal pain = always think AAA.
What you find and how to assess it
Normal finding
- Symmetric, flat or mildly rounded abdomen
- Skin without color change, no ecchymoses
- No visible peristalsis or pulsation
- Midline navel, no bulging
Pathological finding
- Diffuse distension — ileus, ascites, perforation with pneumoperitoneum
- Board-like abdomen — diffuse rigidity = peritonitis, an urgent case
- Grey Turner / Cullen — retroperitoneal bleeding, pancreatitis
- Visible pulsation + pain — AAA, palpate immediately but carefully
Auscultation
You listen before palpating — palpation alters peristalsis
Procedure — how to do it
1
Place the stethoscope diaphragm on the navel. One point is enough — bowel sounds transmit across the whole abdomen. You don’t need to listen to each quadrant separately. Warm the diaphragm with your hand — a cold diaphragm causes abdominal wall tensing and distorts subsequent palpation.
2
Listen for at least 15–20 seconds. Normal is 5–34 sounds per minute — irregular gurgling, bubbling tones every 5–15 seconds. Don’t rush — a silent abdomen needs at least 1 minute of listening before you can declare “ileus.” Mistake: listening for 3 seconds, hearing nothing, and writing “silent.” This is not the correct procedure.
3
Vascular bruits — over the aorta and iliac arteries. Aorta: 2 cm above the navel in the midline. Iliac: 2 cm below and lateral to the navel. A soft systolic bruit = possible stenosis or aneurysm. A bruit over the aorta + abdominal pain = palpate very carefully and think AAA.
What you find and how to assess it
Normal finding
- Regular gurgling sounds every 5–15 s
- No vascular bruits
- Sounds heard evenly
Pathological finding
- Complete silence ≥1 min — paralytic ileus, peritonitis, ischemia
- High-pitched, metallic sounds — mechanical obstruction (bowel “singing”)
- Vascular bruit over the aorta — stenosis or AAA
- Succussion splash — gastroparesis or pyloric stenosis
Percussion
You tap — assessing content and rebound sensitivity
Procedure — how to do it
1
Technique: press the left middle finger firmly on the skin, tap with the middle finger of the right hand. The motion is from the wrist only, not the shoulder. Keep the percussion force constant — compare sound quality, not loudness. Always start from the area where the patient has NO pain — it builds trust and gives you a reference sound.
2
Systematically percuss all four quadrants. Percuss moving from outside toward the center in each quadrant. Note where you find tympany (air — a clear hollow sound) and where you find dullness (fluid, organs, a mass — a muffled sound). Tympany = air in the bowel (normal) or free air (pathological). Dullness = an organ or pathological fluid.
3
Liver — percuss the liver border. Liver dullness begins at the 5th intercostal space in the midclavicular line and ends at the costal margin. Loss of hepatic dullness = free air in the abdominal cavity (perforation). This is one of the most important indirect signs of hollow-organ perforation in the field.
4
Percussion tenderness. A gentle percussion tap over the painful area — if it causes marked worsening = peritoneal irritation. It’s a gentler, kinder test than Blumberg’s sign. In very sensitive patients, you can skip the percussion test — pain from inspection and auscultation will tell you enough.
What you find and how to assess it
Normal finding
- Tympany over the bowel (most of the abdomen)
- Dullness over the liver and spleen
- No percussion tenderness
Pathological finding
- Loss of hepatic dullness — hollow-organ perforation, free air
- Diffuse tympany — paralytic ileus or pneumoperitoneum
- Diffuse dullness — massive ascites (fluid shifts sides with position change)
- Percussion pain — peritonitis, organ inflammation
Palpation
You feel — the most informative, but also riskiest part of the exam
Procedure — how to do it
1
Warm hands, short nails. Warm your hands before palpating — cold hands cause reflex abdominal wall tensing, making a correct exam impossible. The patient should lie supine with knees slightly bent — this relaxes the abdominal wall. The knees-bent position is key — it reduces iliopsoas tension and relaxes the abdominal wall.
2
Start with the quadrant without pain. Light palpation — place the whole hand flat, gentle pressure 1–2 cm deep. Move systematically clockwise through all four quadrants. Watch muscle tension and the patient’s face. The patient’s face tells you more than their verbal description — a grimace or flinch precedes the outcry.
3
Deep palpation — after light palpation. Greater pressure, 4–5 cm deep. You’re looking for: tenderness, guarding (défense musculaire = involuntary muscle tension), masses, organomegaly. Défense musculaire is involuntary — the patient can’t switch it off even if they want to. It differs from voluntary guarding (the patient tenses out of fear).
4
Palpate the painful area — last. Slowly, with anticipation. Note whether the tenderness is localized or diffuse. Never palpate a strongly pulsatile mass hard — if AAA is suspected, only gently confirm the pulsatility and stop palpation immediately.
Specific maneuvers — how they’re performed and what they mean
Blumberg’s sign +
Rebound tenderness — a sign of peritoneal irritation.
Technique: Slowly press deep in the painful area, then suddenly release. Positive = marked worsening of pain on release of pressure, not on pressure itself. Caution: can be falsely negative in elderly patients and after analgesics.
Murphy’s sign +
Cholecystitis — gallbladder inflammation.
Technique: Place your fingers under the right costal margin in the midclavicular line (gallbladder location). Ask the patient to take a deep breath. Positive = the patient stops breathing mid-inhalation due to pain. Falsely negative with a full stomach.
McBurney’s point +
Appendicitis — inflammation of the appendix.
Technique: The point lies on the line between the navel and the right anterior superior iliac spine, one-third of the way from the spine. Tenderness on deep palpation = positive. Combine with Rovsing’s sign.
Rovsing’s sign +
Appendicitis — confirms McBurney’s.
Technique: Press on the left lower quadrant (LLQ). Positive = pain appears in the right lower quadrant (RLQ). Mechanism: pressure pushes air and cecal contents toward the appendix.
Psoas sign +
Retrocecal appendix or retroperitoneal pathology.
Technique: Patient on the left side. Passively extend the right hip joint (extend the thigh backward). Positive = pain in the right iliac region. Alternative: the patient actively raises the right leg, bent at the knee, against your resistance.
CVA tenderness
Pyelonephritis or ureteropelvic junction obstruction.
Technique: Patient sitting or standing. Gently strike the costovertebral angle (where the last rib meets the spine) with your fist, on both sides. Positive = unilateral pain on the jolt. Don’t use force — just a gentle impulse.
⚠ A critical situation during palpation
If deep palpation of the epigastrium or periumbilical area reveals a pulsatile mass — STOP palpation IMMEDIATELY. Don’t verify further. IV access, monitoring, urgent transport with pre-notification: “suspected AAA.” Any further manipulation can cause rupture.
Vital signs and supplementary measurements
The minimum standard for every patient with abdominal pain
What to measure, why, and how to interpret it
1
BP on both arms. A systolic BP difference >20 mmHg = asymmetry = suspect aortic dissection. In an unstable patient, measure BP every 3–5 minutes during transport. A single BP reading is insufficient if there’s back pain or a hemodynamically unstable patient.
2
Heart rate + pulse character. Tachycardia >100/min in a patient with abdominal pain = always pathological. Irregular pulse = atrial fibrillation → think mesenteric ischemia. Weak, thready pulse = hypovolemia/shock. A “normal” heart rate doesn’t rule out compensated shock — watch BP and capillary refill.
3
12-lead ECG — mandatory. Inferior STEMI (II, III, aVF) or right-ventricular STEMI presents with epigastric pain, nausea, and vomiting. Obtain an ECG in every patient with abdominal pain without a clear mechanical cause. A paramedic who doesn’t run an ECG for abdominal pain is making a fundamental error — and it’s a common cause of malpractice claims.
4
Blood glucose. DKA (diabetic ketoacidosis) causes intense abdominal pain, nausea, and vomiting — and looks exactly like an “acute abdomen.” Glucose >14 mmol/l + acetone breath + tachycardia + abdominal pain = DKA until proven otherwise. A glucometer is in every basic- and advanced-level EMS kit — there’s no excuse for not checking glucose.
5
Temperature. Fever >38°C + abdominal pain = inflammatory etiology (appendicitis, cholecystitis, diverticulitis, pyelonephritis, peritonitis). Hypothermia + abdominal pain + tachycardia = advanced-stage septic shock. Afebrile does NOT rule out inflammation — immunosuppressed and elderly patients can have severe peritonitis without fever.
Part 03
Differential diagnosis — from symptom to diagnosis
Based on pain location, character, and physical findings, you build a working diagnosis. The table is ordered by urgency — always start with the most dangerous possibility and rule out downward.
| Diagnosis | Key signs and findings | Urgency |
|---|---|---|
| AAA — ruptured / symptomatic | Pulsatile mass, back pain, BP ↓↓, male >60 y, smoker | LIFE-THREAT |
| Inferior STEMI / RV infarction | Epigastric pain + nausea + vomiting, ECG → ST elevation II, III, aVF | LIFE-THREAT |
| Mesenteric ischemia | Pain out of proportion to the finding, AFib, age >60 y, silent abdomen with severe pain | LIFE-THREAT |
| Hollow-organ perforation | Sudden onset, board-like rigidity, tachycardia, loss of hepatic dullness | CRITICAL |
| Ectopic pregnancy | Woman of reproductive age, RLQ pain, amenorrhea, syncope, BP ↓ | CRITICAL |
| Appendicitis | McBurney +, Rovsing +, migration from the umbilicus, anorexia, fever | URGENT |
| Acute cholecystitis | Murphy +, RUQ pain + shoulder, febrile, overweight woman >40 y (but not always) | URGENT |
| Acute pancreatitis | Epigastrium + back, marked nausea, relief leaning forward, alcohol/gallstones | URGENT |
| Upper / lower GI bleeding | Melena/hematemesis/rectal bleeding, tachycardia, syncope, anemia | URGENT |
| DKA — diabetic ketoacidosis | Glucose >14, acetone breath, tachycardia, Kussmaul breathing, abdominal pain | URGENT |
| Diverticulitis | LLQ pain, age >50, febrile, change in bowel habits, no sudden perforation | SEMI-URGENT |
| Ureterolithiasis | Colic radiating to the groin/genitals, CVA tenderness +, hematuria, no peritoneal irritation | SEMI-URGENT |
ℹ Clinical pearl — pain out of proportion to the finding
A patient with very severe abdominal pain (VAS 8–10) and a minimal physical finding (soft abdomen, no tenderness on palpation) = always think mesenteric ischemia. This disproportion is its classic sign. Mortality exceeds 70% when diagnosis is delayed.
Literature and Sources
Sources used
The content of this article is based on recommendations and textbooks of emergency medicine and prehospital care. Each source notes what it primarily concerns.
01
Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed.
Physical examination of the abdomen, differential diagnosis of abdominal pain, mesenteric ischemia, AAA.
02
Rosen’s Emergency Medicine: Concepts and Clinical Practice, 9th ed.
Clinical maneuvers (Murphy, McBurney, Rovsing, Psoas, Blumberg), interpretation of peritoneal signs.
03
Pre-Hospital Emergency Care, 11th ed.
The OPQRST protocol in the prehospital context, primary and secondary patient assessment, load-and-go indications.
04
Urgentní medicína v klinické praxi lékaře
Prehospital approach to acute abdominal conditions, indications for urgent surgery, differential diagnosis within the Slovak/Czech EMS system.
05
Náhlé příhody břišní v přednemocniční péči
Classification of acute abdominal conditions, field physical examination, transport indications.
06
Acute Mesenteric Ischemia: Guidelines of the World Society of Emergency Surgery
Diagnostic criteria for mesenteric ischemia, pain/finding disproportion, mortality from delayed diagnosis.
07
2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease
Symptomatic and ruptured AAA — clinical presentation, palpation, transport, pre-notification.
08
Slovak Act No. 579/2004 Coll. on Emergency Medical Services and on Amendments to Certain Acts
Legal framework for a paramedic’s practice, scope of competency in examining and treating patients in the field.
09
Decree of the Slovak Ministry of Health No. 143/2009 Coll. — Professional Guidance for Paramedics
Paramedic competencies for physical examination and documentation of findings.
✓ Article update
This article was last updated in accordance with available professional guidance. Content will be revised if applicable legislation changes or new guidelines are published. If you found an inaccuracy, report it via the contact form on zachranarjecool.eu.