Shadow Health Focused Exam: Abdominal Pain and Abdominal Assessment Guide (with Practice Cases)
10 min read In this guide
- What the Shadow Health Focused Exam: Abdominal Pain evaluates
- Using location to narrow possible causes
- A step-by-step Shadow Health abdominal assessment in the correct order
- Special signs: Murphy’s, McBurney’s, rebound tenderness and CVA tenderness
- Two practice cases (gallbladder and urinary tract) with documentation
- Patient education, common mistakes and FAQs
Why the abdominal pain focused exam matters
Abdominal pain has dozens of possible causes, from indigestion and constipation to appendicitis, gallbladder disease, pancreatitis, bowel obstruction, urinary tract infection, kidney stones and gynecologic emergencies such as ectopic pregnancy. The Shadow Health Focused Exam: Abdominal Pain tests your ability to gather a detailed history, perform a careful abdominal assessment in the correct sequence and recognize signs that need urgent attention (Jarvis & Eckhardt, 2024). For a comparison with other focused exams, see our Shadow Health Focused Exams: Complete Guide.
Step 1: Use location as your first clue
| Region | Organs | Possible causes |
|---|---|---|
| Right upper quadrant | Liver, gallbladder, part of duodenum, right kidney | Cholecystitis, gallstones, hepatitis, right kidney problems |
| Epigastric | Stomach, pancreas, duodenum | Gastritis, peptic ulcer, reflux, pancreatitis; also consider the heart |
| Left upper quadrant | Stomach, spleen, pancreas, left kidney | Gastritis, splenic problems, pancreatitis |
| Periumbilical | Small intestine | Early appendicitis, gastroenteritis, obstruction |
| Right lower quadrant | Appendix, cecum, right ovary and tube | Appendicitis, ovarian cyst or torsion, ectopic pregnancy |
| Left lower quadrant | Sigmoid colon, left ovary and tube | Diverticulitis, constipation, ovarian problems |
| Suprapubic | Bladder, uterus | Urinary tract infection, urinary retention, pelvic inflammatory disease |
| Flank | Kidneys, ureters | Kidney stones, pyelonephritis |
Step 2: Subjective data for abdominal pain
- OLDCARTS: onset (sudden vs. gradual), exact location and any migration, duration, quality (cramping, burning, sharp, colicky), aggravating and relieving factors, timing (relation to meals, bowel movements, menstrual cycle), severity
- Gastrointestinal symptoms: appetite, nausea, vomiting (and what it looks like), diarrhea, constipation, last bowel movement, gas, bloating, blood in stool, black tarry stool, difficulty swallowing, heartburn
- Urinary symptoms: burning, urgency, frequency, blood in urine, flank pain
- Reproductive history: last menstrual period, possibility of pregnancy, contraception, vaginal bleeding or discharge, sexually transmitted infection risk
- Systemic symptoms: fever, chills, jaundice, weight loss, fatigue
- History: previous abdominal surgeries, gallstones, ulcers, inflammatory bowel disease, liver disease, kidney stones
- Medications and substances: NSAIDs, aspirin, opioids, antibiotics, iron, alcohol
- Diet: fatty meals, fiber, fluids, recent foods and food safety, travel
Step 3: The Shadow Health abdominal assessment
The abdominal exam has a unique order: inspection, auscultation, percussion, palpation. Auscultating before touching the abdomen prevents palpation and percussion from changing bowel sounds (Ball et al., 2023). Position the patient supine with knees slightly bent, and examine the painful area last.
Inspection
- Contour (flat, rounded, distended, scaphoid) and symmetry
- Skin: scars, striae, bruising, jaundice, rashes, dilated veins
- Umbilicus, visible peristalsis or pulsations, hernias
- Patient’s position and movement: lying still (peritoneal irritation) or restless (colicky pain such as kidney stones)
Auscultation
- Bowel sounds in all four quadrants: normal, hypoactive or hyperactive. Listen for up to five minutes before documenting absent bowel sounds.
- Vascular sounds: bruits over the aorta, renal, iliac and femoral arteries.
Percussion
- Tympany over gas-filled bowel; dullness over organs, fluid or masses
- Liver span at the right midclavicular line
- Costovertebral angle (CVA) tenderness: gentle fist percussion over the kidneys
Palpation
- Light palpation in all quadrants for tenderness, guarding and muscle tone
- Deep palpation for organs and masses, ending with the painful area
- Liver, spleen and kidneys as indicated
Special signs
| Sign | How it is assessed | Suggests |
|---|---|---|
| Murphy’s sign | Patient stops inhaling when the examiner presses under the right costal margin | Cholecystitis |
| McBurney’s point tenderness | Tenderness one-third of the way from the right anterior superior iliac spine to the umbilicus | Appendicitis |
| Rebound tenderness | Pain when pressure is quickly released | Peritoneal irritation |
| Rovsing’s sign | Pressing the left lower quadrant causes right lower quadrant pain | Appendicitis |
| Psoas and obturator signs | Pain with hip flexion against resistance or internal rotation | Appendicitis or pelvic irritation |
| CVA tenderness | Pain with percussion over the flank | Pyelonephritis, kidney stone |
Red flags in abdominal pain
Report immediately: sudden severe pain; rigid, board-like abdomen or rebound tenderness; vomiting blood or coffee-ground material; black or bloody stools; distention with no bowel movement or gas and vomiting (possible obstruction); fever with localized tenderness; fainting or low blood pressure; possible pregnancy with pain or bleeding; a pulsating abdominal mass.
Practice case 1: right upper quadrant pain
Original practice case for learning; not taken from Shadow Health and not an answer key.
Patient: Sandra Lee, 47, office manager. “I get terrible pain under my right ribs after I eat.”
Subjective: three episodes over two weeks of right upper abdominal pain starting 30–60 minutes after fatty meals, lasting several hours, cramping then constant, 8/10, spreading to the right shoulder blade; current episode started 10 hours ago and has not eased; nausea and vomiting twice; feels feverish. BMI 33; recently lost 20 pounds on a rapid weight-loss diet. Takes no regular medicines. Last menstrual period one week ago. Denies urinary symptoms, black stools or jaundice.
Objective: T 100.9°F, HR 102, BP 132/84, RR 18. Lying still, holding right side. Abdomen rounded, no scars. Bowel sounds hypoactive. Tympanic except over the liver; no CVA tenderness. Tenderness and guarding in the right upper quadrant; positive Murphy’s sign; no rebound tenderness; no masses. Sclera not yellow.
Clinical reasoning
- Cues: postprandial right upper quadrant pain radiating to the right scapula, fever, nausea and vomiting, positive Murphy’s sign, obesity, rapid weight loss.
- Analysis: findings are consistent with acute cholecystitis (gallbladder inflammation, usually due to gallstones blocking the cystic duct). Rapid weight loss and obesity are risk factors for gallstones.
- Actions: report findings; anticipate NPO status, labs and imaging as ordered; monitor vital signs, pain and for signs of jaundice or worsening infection; teach about the condition and diet after recovery.
Sample documentation
Subjective: 47-year-old female reports RUQ pain after fatty meals, 3 episodes × 2 weeks; current episode × 10 hours, constant, 8/10, radiating to right scapula; associated nausea, emesis × 2 and subjective fever. Recent 20-lb weight loss on rapid diet. LMP 1 week ago. Denies dysuria, hematuria, melena, hematochezia or jaundice.
Objective: T 100.9°F, HR 102, BP 132/84, RR 18. Lying still, guarding right side. Abdomen rounded, symmetric, no scars or distention. Bowel sounds hypoactive × 4 quadrants; no bruits. Tympanic to percussion except over liver; no CVA tenderness. RUQ tenderness with guarding; Murphy’s sign positive; no rebound; no masses or organomegaly palpated. Sclerae anicteric. Findings reported to provider.
Practice case 2: suprapubic pain
Patient: Mei Chen, 24. “It burns when I pee, and my lower belly aches.”
Subjective: 2 days of burning urination, urgency, frequency and suprapubic pressure, 4/10; cloudy urine; no fever, flank pain, vaginal discharge or nausea; sexually active, uses condoms inconsistently; last menstrual period 2 weeks ago.
Objective: T 98.8°F, HR 84. Mild suprapubic tenderness; no CVA tenderness; bowel sounds normal; no guarding.
Reasoning: findings suggest an uncomplicated lower urinary tract infection; absence of fever and CVA tenderness makes kidney infection less likely. Anticipate urinalysis and a pregnancy test as ordered; teach fluids, completing any prescribed antibiotics, voiding after intercourse and warning signs such as fever or flank pain.
Sample documentation: suprapubic pain case
Subjective: 24-year-old female reports dysuria, urgency, frequency and suprapubic pressure 4/10 × 2 days with cloudy urine. LMP 2 weeks ago; sexually active with inconsistent condom use. Denies fever, flank pain, vaginal discharge, nausea or vomiting.
Objective: T 98.8°F, HR 84, BP 116/72. Abdomen soft, nondistended; bowel sounds active × 4 quadrants; mild suprapubic tenderness to palpation; no guarding or rebound; no CVA tenderness bilaterally.
Patient education opportunities
- Diet changes such as smaller meals, less fat and more fiber, depending on the cause
- Safe use of NSAIDs and alcohol
- Hydration and bowel habits
- Warning signs that need emergency care
- Safer sex practices and urinary tract infection prevention
Common mistakes in the abdominal pain focused exam
- Palpating before auscultating
- Palpating the painful area first, which causes guarding and an unreliable exam
- Forgetting the last bowel movement, urinary symptoms and menstrual and pregnancy history
- Not assessing CVA tenderness
- Skipping special signs when the history suggests appendicitis or gallbladder disease
- Documenting “abdomen soft, nontender” without describing each component
Sample interview flow for the abdominal pain exam
Example questions you might type, in a logical order. Adapt the wording to each patient.
- “Hello, I’m [name], the nurse who will be examining you today. Can you confirm your name and date of birth?”
- “Tell me about the pain. When did it start?”
- “Can you point to where it hurts most? Has the pain moved since it started?”
- “How would you describe it: cramping, burning, sharp, dull or coming in waves?”
- “Is it constant or does it come and go? Is it related to eating?”
- “What makes it worse or better? Have you taken anything for it?”
- “Have you had nausea, vomiting, diarrhea or constipation? When was your last bowel movement?”
- “Have you seen any blood in your stool or vomit, or black stools?”
- “Any burning with urination, frequent urination or blood in your urine?”
- “When was your last menstrual period? Is there any chance you could be pregnant?”
- “Any fever, chills, yellowing of the skin or weight loss?”
- “Have you had abdominal surgery or problems with your gallbladder, stomach or bowels?”
- “Do you take NSAIDs such as ibuprofen, or drink alcohol? How much?”
- “I can see this is very uncomfortable. I’ll be gentle and examine the painful area last.”
Abdominal exam checklist
- Ask about pain, GI, urinary, reproductive and systemic symptoms
- Inspect contour, skin, symmetry and patient position
- Auscultate bowel sounds in all four quadrants and listen for bruits before touching
- Percuss for tympany and dullness, liver span and CVA tenderness
- Palpate lightly, then deeply, painful area last
- Perform special signs when indicated (Murphy’s, McBurney’s, rebound, Rovsing’s, psoas, obturator)
- Teach diet, medication safety and warning signs
- Document each component and report abnormal findings
Frequently asked questions
Why do I auscultate before palpating the abdomen?
Touching the abdomen can stimulate or alter bowel activity, so listening first gives a more accurate picture of bowel sounds.
How long should I listen before saying bowel sounds are absent?
Many textbooks recommend listening for up to five minutes in a quadrant before documenting absent bowel sounds, because normal sounds can be irregular.
Why ask about pregnancy in abdominal pain?
Pregnancy-related conditions, including ectopic pregnancy, can cause abdominal pain and are emergencies. Pregnancy also affects which tests and medications are safe.
What does guarding mean?
Guarding is tightening of the abdominal muscles when the abdomen is touched. Voluntary guarding is the patient tensing because of fear or tickling; involuntary guarding, or rigidity, persists despite relaxation and suggests peritoneal irritation.
Should I check for CVA tenderness even if the pain is in the abdomen?
Yes. Kidney stones and kidney infections can cause abdominal or flank pain, so CVA tenderness helps you distinguish urinary from gastrointestinal causes.
More in the series: Shadow Health Focused Exam: Chest Pain, Shadow Health Focused Exam: Cough and Shadow Health Documentation.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier.
Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.
