 Welcome back to Approach in Abdominal Pain. In this section, we will discuss how to use the signs on physical examination to narrow down the diagnosis. We'll divide it into the vital signs, the general appearance of the patient, the abdominal exam, and other physical examination that might help us. When we first look at the vital signs, the patients who have abdominal pain might have tachycardia based on pain alone. If they have a fever, it suggests an inflammatory or infectious cause. A low oxygen saturation suggests a respiratory problem. What about if the vital signs are unstable? If the patient is hypotensive or persistently tachycardic even after a good analgesia, then we're worried that the patient is in shock. In patients with abdominal pain, two main causes of shock include septic shock or hemorrhagic shock. Next, the general appearance of the patient. In particular, we would like to know if the patient is comfortable when they move. We're trying to elicit whether they have peritonitis. Peritonitis occur after bacterial contamination and inflammation of the peritoneal lining. In patients who have localized peritonitis, they will have difficulty walking. In patients with generalized peritonitis, they tend to want to lie still on the stretcher without moving. Conditions that can give localized peritonitis include infections such as appendicitis and diverticulitis, inflammation such as pancreatitis and ischemiculitis. Once the bacteria is spread to the generalized peritoneum, the patient will have generalized peritonitis following. Other conditions that can also give generalized peritonitis include GI perforation, either from an ulcer or bowel obstruction. Patients with generalized peritonitis is a very sick patient. After we look at the patient's vital signs and general appearance, we want to do a focused abdominal exam. That includes observation, auscultation and palpation. First, observation. The main observation would be looking for surgical scars. The scars will tell you what surgery the patients have had in the past. Previous surgery increased the risk of ahesions and increased the risk of bowel obstruction. We also want to look out for hernia before examining the patient further. For auscultation, we'll be listening for bowel sounds. They can either be decreased or increased. Bowel sounds can be decreased in an alias. Alias is nonspecific and can be associated with multiple abdominal conditions. In the patients with increased bowel sounds, we tend to think about infectious cause such as gastroenteritis or in bowel obstructions. There are other sounds we want to auscultate as well. They include the lungs if we're suspicious of pneumonia, especially if the patient is presenting with right upper quadrant or left upper quadrant pain, heart sounds if the patient is presented with epigastric pain, and brewery if we're worried about a vascular lesion in the abdomen. Next, we want to palpate for tenderness. We hope to narrow down the diagnosis by looking for the maximal point of tenderness. What if the patient is in a lot of pain and unable to tell us where the point of maximal tenderness is? It is perfectly fine to give a patient analgesia to make them more comfortable before examining them further. When the patient is more comfortable, it is a lot easier to look for the maximal point of tenderness. If we can localize the patient's maximal tenderness to an area of the abdomen, it helps us localize the diagnosis similar to what we did in the previous video. We're also looking for rebound tenderness and guarding that suggests of a localized peritonitis. We'll be palpating for mass and hernia. In the case of hernia, we need to make sure that they're soft and reducible. Depending on where the pain is, we might need to look into other systems beside the GI tract. Patients with right upper quadrant and left upper quadrant pain might need a respiratory exam. Those with epigastric pain might need a cardiac exam. Those with flank pain might need an exam for their kidneys specifically. For those with right lower quadrant and left lower quadrant pain, we need to add on a testicular exam or a pelvic exam. What are we looking for in the testicular exam? We're looking for swelling, tenderness, any sign of torsion, and presence of hernia. On a pelvic exam, we would look for a discharge that's suggestive of a tubular anapsis or a pelvic inflammatory disease, a nexotenderness that can be suggestive of an ectopic pregnancy or tubular anapsis, and pelvic bleeding that is suggestive of an ectopic. In a summary, discuss the physical examination maneuvers we'd like to use in the patient with abdominal pain. In the next section, we'll discuss the workup and investigations. We hope you find this helpful. Thank you for watching.