19) Elderly patient (> 65 yrs) – (minimal peritoneal signs so that fever, sepsis, and confusional states may be due to occult cholecystitis or cholangitis)
20) Hematemesis, melena (peptic ulcer)
21) Unintentional weight loss of > 5 kg (malignancy)
22) Past abdominal surgery (adhesions)
23) Diabetes (minimal peritoneal signs so that fever, sepsis, and confusional states may be due to occult cholecystitis or cholangitis)
24) Unexplained upper abdominal pain and weight loss with or without backache (UGIE to exclude GIT Ca)
25) Unexplained abdominal pain in a female with abdominal and/or VE mass (exclude ovarian Ca if not due to fibroids, GIT or GUS masses)
26) Woman in reproductive age, bleeding PV, abdominal pain, POA +/-, shock out of proportion to blood loss, shoulder tip pain (immediate transfer with IV drip to maintain radial pulse, high flow oxygen)
27) Woman undergoing IVF or any other assisted conception, collapse or shock or faintishness (Ovarian Hyperstimulation Syndrome – immediate referral to a gyn)
28) Abdominal pain referral – right scapula (gall bladder), left shoulder (ruptured spleen, pancreatitis), pubis or vagina (renal pain), back (ruptured aortic aneurysm)
29) HELLP syndrome – woman with a POA > 20/52 or 72-96 hrs after delivery, abdominal pain, RHC pain, malaise, weight gain, edema, nausea, vomiting, low BP, proteinuria, elevated liver enzymes, platelet count less than 100,000, microhemolytic anemia, elevated S. bilirubin,
30) Late stages of pregnancy, hypertension, proteinuria, edema, upper abdominal pain, mostly epigastric or RHC, headache, nausea, vomiting, visual disturbances, hyperreflexia, reduced urine output, fits (Severe pre-eclampsia)
31) Constant severe abdominal pain, pregnancy more than 26 weeks, uterus hard and tender, bleeding per vaginam, shock out of proportion to the blood loss (due to internal uterine haemorrhage), (Placental abruption)
32) Abdominal pain, POA < 20/52, bleeding per vaginam, heavy bleeding, tachycardia, bradycardia, hypotension, passage of products of conception, severe abdominal pain (immediate gyn assessment for ectopic, incomplete abortion)
33) Elderly patient with abdominal pain, vomiting, diarrhea – acute gastroenteritis is rare in the elderly, consider this as a non-specific presentation of any of following GIT lesions – gall bladder disease, acute appendicitis, diverticulitis, bowel obstruction, mesenteric ischemia
34) Elderly patient with abdominal pain and AF, atherosclerotic markers (N), low ejection fraction – mesenteric ischemia
35) Elderly patient with recent onset dyspepsia – dyspepsia never starts in the elderly, postprandial pain in the elderly with atherosclerotic markers may be intestinal angina a sign of mesenteric ischemia, peptic ulcer disease
36) Elderly patient with renal colic – exclude abdominal aortic aneurysm as renal colic in the elderly is uncommon
37) Elderly patient with recent onset backache thought to be due to lumbar muscle sprain or musculoskeletal cause - remember musculoskeletal problems are less common among the elderly, exclude AAA as a cause of severe backache in the elderly
38) Pregnancy < 22 weeks, palpable tender discrete mass in lower abdomen, light vaginal bleeding, adnexal mass on VE, (Ovarian cyst)
39) Pregnancy < 22 weeks, lower abdominal pain, low grade fever, rebound tenderness, abdominal distension, anorexia, nausea/vomiting, paralytic ileus, increased WBC, site of pain right flank or RHC (Acute appendicitis)
43) Pregnancy < 22 weeks, abdominal pain, light bleeding (takes longer than 5 min for a clean pad or cloth to be soaked), closed cervix, uterus slightly larger than normal, uterus softer than normal, fainting, tender adnexal mass, amenorrhea, cervical motion tenderness (Ectopic pregnancy)
44) Pregnancy > 22 weeks, palpable contractions, blood stained mucus discharge, watery discharge usually before 37 weeks, cervical dilation and effacement, light vaginal bleeding (Preterm labour)
46) Pregnancy > 22 weeks, intermittent or constant abdominal pain, bleeding after 22 weeks of pregnancy, blood may be hidden in uterus rather than shown PV, shock, tense, tender, uterus, decreased, absent fetal movements, fetal distress or absent fetal heart sounds (Abruptio placentae)
55) Pregnancy < 22 weeks, palpable tender discrete mass in lower abdomen, light vaginal bleeding, adnexal mass on VE, (Ovarian cyst)
56) Pregnancy > 22 weeks, abdominal pain upper abdomen, headache, visual disturbance, generalized edema, brisk reflexes, reduced urine output, BP 140/90 or any rise in DBP from a previous reading, ankle edema, proteinuria, fitting, confusional state, (Preeclampsia)
57) First episode of abdominal pain over 50 yrs person exclude gastric or pancreatic carcinoma
58) Elderly patient, evidence of atherosclerosis markers (N), angina, intermittent claudication, epigastric or mid-abdominal pain, pain starts 15-20 min postprandial, lasts 2 hrs, weight loss, progressive loss of weight (Mesenteric angina)
59) Abdominal pain, perianal fistulae, perianal sinuses, malabsorption syndrome (Abdominal pain without diarrhea as a presenting symptom of IBD)
60) Jaundice, anorexia, weight loss, recurrent abd pain, past gall stones, alcoholism (Pancreatic disease)
61) Alcoholism
62) Medical causes of abdominal pain – inferior myocardial infarction, pneumonia, pulmonary infarction, diabetic ketoacidosis, IBD, pyelonephritis
63) Elderly patient with moderate to severe pain, any abnormality in vital signs, altered level of consciousness (Life threatening disease – admit immediately)
65) Epigastric pain with cardiac risk factors (DM, HT, smoking, age above 55 yrs, past angina or unstable angina or MI, Hyperlipidemia, past strokes and CVA, F/H of cardiovascular disease before 50 yrs in male 60 yrs in female relatives, F/H suggestive of familial hyperlipidemia)