Hemodynamic instability, in conjunction with

fever and warm skin, points toward septic shock; the presence of cold and clammy skin suggests hypovolemic shock.

The general appearance of the patient can provide

important diagnostic information. The inability to lie still

or find a position of comfort is seen with ureteral colic,

ovarian torsion, and mesenteric ischemia. Patients with

peritonitis-whose pain is worsened with movementprefer to lie still.

A thorough abdominal examination should be performed, starting with visual inspection, followed by auscultation, and then palpation. Inspection may reveal

abdominal distention or surgical scars from surgeries not

initially volunteered by the patient. The presence of hyperactive high-pitched bowel sounds may signify a small

bowel obstruction. Palpation should begin with a nontender location followed by the tender quadrants. One

should look for the presence of guarding (contraction of

the abdominal wall musculature) as well as facial grimacing. Rebound tenderness lacks sensitivity or specificity as a

finding of peritonitis. A more specific marker is "cough

pain." The patient is asked to cough, and the examiner

looks for signs of pain such as flinching, grimacing, or

CHAPTER 26

Right Upper Quadrant Epigastric Left Upper Quadrant

Biliary: col ic, cholecystitis, cholangitis Bil iary disease: colic, cholecystitis, cholangitis l Gastric: PUD, gastritis

Hepatic: hepatitis, abscess Gastric: PUD, gastritis Splenic: infarct, rupture

Pancreatitis Pancreatitis Pancreatitis

Renal: nephrolithiasis, pyelonephritis Cardiac: ACS Renal: nephrolithiasis, pyelonephritis

Intesti nal: retrocecal appendicitis j Vascular: AAA, aortic dissection

J

Pulmonary: pneumonia,