Gastritis: Mid-epigastric pain may be exaggerated by stress/emotions, diet,
medication—particularly non-steroidal anti-inflammatory drugs. Patients
frequently give a history of tobacco or alcohol use; they may use NSAIDs.
Patients may state that spicy foods seem to aggravate the pain. May have
nausea and decreased appetite. Bowels are usually not affected, unless
there is a component of irritable bowel syndrome and stress, in which case
there may be either decreased or increased stooling.
Irritable bowel syndrome (IBS):
Loose stools or diarrhea
Mucus in stools
Diagnosis of exclusion
Symptoms can be initiated by gastroenteritis and can be aggravated
by stress, dietary changes or change in activity, often unpredictable.
Often starts with dull visceral pain in periumbilical region
Presentation hallmark: Fairly acute onset of moderate to severe right
lower quadrant pain.
Vomiting, nausea, loss of appetite, mild fever, and decreased stooling
Because of its morbidity and mortality, it is important to rule this out
with more history and a good physical exam.
Look for positive psoas sign, rebound tenderness.
Pelvic inflammatory disease (PID):
Abdominal or pelvic pain that is worse with sexual intercourse or with
activities such as running or jumping, which cause jarring of the pelvic
*Pathognomonic: Cervical motion tenderness, known as a positive
Mild menstrual irregularities
Significant morbidity, which increases with the severity of the disease
and length of time to diagnosis.
1 in 4 women who have a single episode of PID later experience tubal
infertility, chronic pelvic pain, or an ectopic pregnancy (as a result of
scarring and adhesions).
Tubal adhesions leading to infertility in 33% of women after their first
episode of PID, and up to 50% after the second pelvic infection.
Need sexual history for both partners, pelvic exam, labs, and imaging
Growth of the uterus and stretching of the broad ligaments during a normal pregnancy can cause mild to moderate discomfort in the lower
Symptoms of nausea and vomiting could be caused by pregnancy.
This is more a diagnosis of exclusion, but you would not want to miss
a pregnancy. (Certain medications should not be given to women who
are pregnant. Fetuses should not be exposed to radiation.)
History and labs may be needed.
Patients present with divergent symptoms ranging from no pain and
normal menses to intense pain and irregular or absent menses
Medical emergency. Early medical treatment reduces need for
surgery, but if a fallopian tube is in danger of rupture, surgical
intervention may be necessary.
Need date of the patient's last menstrual period (LMP), her menstrual
history, most recent intercourse dates, types of contraception used in
past few years, history of any vaginal or pelvic infections, and history
of previous ectopic or normal pregnancies
Patients who are pregnant, or even those in whom there may be the
suspicion of pregnancy, are at increased risk of being victims of
The stress of being the victim of domestic violence may cause
irregular menses in some women.
Abdominal pain and cramping may come, not only from the inflicted
trauma, but also from the patient's somatization of her stress.
Bruises, of various colors, denoting various stages of healing, can be
seen on any part of the body, but especially on the abdomen as this
would cause trauma to a fetus, and because they would be less visible
to the general public.
Careful history: Be aware of the patient's body language and response
to touch. Consider the consistency of the history with the exam.
Examine the patient thoroughly in a gown so that all areas can be
If patient is trying to hide the diagnosis, serious injuries may be
missed, such as ruptured internal organs or fractures. There is always
a risk of recurrent violence. The source of the trauma should be
determined, because, for example, it might be life-saving to uncover
that the patient is at increased risk due to weapons in the home.
Generally a moderately severe to severe epigastric pain accompanied
by nausea and vomiting.
Usually a history of alcohol use/abuse or a family history of
Other causes include gallstones or hypertriglyceridemia.
Acute attacks generally require hospitalization.