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Onset: When did your pain begin?

Palliation/Provocation: What were you doing when your pain started? What makes your pain better or worse? If you have taken anything for the pain, has it changed your symptoms? Are you more comfortable in a certain position?

Quality: Can you describe what your pain feels like?

Radiation: Do you feel pain anywhere else? Does the pain move to any other place?

Severity: How bad is your pain on a scale from 1 to 10, if 10 is the worst pain you can imagine?

Timing: Since it started, has your pain changed in quality, severity, or location?

The patient’s general appearance should be assessed. Seasoned EMS clinicians develop an immediate impression of those who are “sick.” A patient who limits his or her movement due to abdominal pain may have peritonitis, as opposed to one who cannot find a position of comfort (e.g., kidney stones or aneurismal pain).

The focus of the physical examination should be to identify potentially life‐threatening conditions. Assessment and monitoring of vital signs is crucial. Indications of shock, including hypotension, tachycardia, narrow pulse pressure, tachypnea, or low end‐tidal CO₂ should be recognized. A hypotensive patient should be presumed to have a serious medical condition requiring immediate intervention.

A careful examination of the heart and lungs should be completed. Abnormal or diminished lung sounds may indicate pneumonia or pleural effusion, which may present as ipsilateral upper abdominal pain. Cardiac auscultation may detect murmurs or gallop rhythms, which may be associated with an acute myocardial infarction or heart failure presenting with vague abdominal pain or GI symptoms as the chief complaint.

EMS clinicians should perform a brief, directed examination of the abdomen. Inspection of the abdomen should be performed to detect distention, skin lesions, or bruising. The presence of therapeutic appliances such as cardiac assist devices, feeding tubes, dialysis access ports, ostomies, and urinary catheters should be noted, as well as their appearance and the condition of surrounding skin. Auscultation of bowel sounds is neither accurate nor productive in the out‐of‐hospital setting. Similarly, percussion does not yield any important findings in these patients.

Palpation should first be performed in the areas away from the region of discomfort. The area of pain should be assessed last with gradually increased pressure to allow some qualification of the level of discomfort (e.g., pain with gentle palpation). Specific findings such as Murphy’s sign, Rovsing’s sign, obturator sign, and psoas sign are neither sensitive nor specific. Percussion of the patient’s heel while the leg is fully extended, or noting pain with movement of the ambulance, may be more effective than depressing and releasing the abdominal wall to detect rebound tenderness. Deep palpation to detect a pulsatile mass in the abdomen is discouraged due to its low yield and theoretical potential for exacerbating the patient’s condition if an aortic aneurysm is present.