TL;DR (Fast Track Summary)
Purpose: Help new providers avoid the most common abdominal pain mistakes.
Do this first: Localize the pain, assess stability, get a pregnancy test, get a UA.
Red flags: Guarding, rebound, persistent tachycardia, hypotension, GI bleeding signs.
Initial tests: UA, pregnancy test, CBC, CMP, lipase; imaging based on location + red flags.
First steps: Stabilize, rule out “can’t miss” causes, build a structured differential.
Follow-up: Clear return precautions; consider 12–24 hour reassessment for stable patients with vague pain and negative workup.
It Could Be Anything…
Abdominal pain is one of the hardest complaints for new providers to work through because there are so many variables to consider, and not a lot of time to do it.
The good news is, you don’t need to remember every single diagnosis. You just need to know the things NOT to miss (e.g. the “Big, Bad, Scary”) and a practical approach to figuring that out.
10 Abdominal Pain Mistakes to Avoid
1. Skipping the pregnancy test
Even if the patient “can’t be pregnant.” Even if they’re on birth control. Even if they swear they’re not sexually active.
Why it matters: Ectopic pregnancy is one of the highest-risk missed diagnoses.
Fix: Order it automatically for anyone with a uterus and abdominal pain.
2. Getting fooled by a “normal” exam
You’ll see this a lot: the patient looks fine, vitals are good, belly’s soft… but something is just not quite right.
Why it matters: Early appendicitis, bowel obstruction, and peritonitis can all initially present with a normal exam.
Fix: Ask about the drive over — did bumps hurt? Have them stand, walk, or hop. Pain that gets worse when they move around should have you looking a little closer.
3. Avoiding a pelvic exam
Every new provider hesitates here. It’s totally normal to feel uncomfortable, especially if you don’t have a lot of exposure or experience. But if you skip this, you are doing a disservice to the patient AND your license. There are simply too many things you can miss by skipping the pelvic exam.
Why it matters: PID, ovarian torsion, tubo-ovarian abscess, and ectopic pregnancy can all present as vague lower abdominal pain.
Fix: If the pain is below the umbilicus, you need either:
- a pelvic exam WITH A CHAPERONE or
- a very clear, documented reason why it’s not indicated.
4. Forgetting constipation is a diagnosis but also a symptom.
Constipation is common, and sometimes the patient just needs more water and fiber. But it can also be a sign of something more serious.
Why it matters: Constipation can coexist with SBO, volvulus, appendicitis, or diverticulitis.
Fix: Ask about red flags: vomiting, inability to pass gas or stool, abdominal distension, weight loss, or severe pain.
5. Assuming RUQ pain = gallbladder.
RUQ pain has dangerous mimics many new grads don’t think of:
- Lower lobe pneumonia
- PE (yep, really)
- ACS, especially in females or diabetics
- Pancreatitis
Fix: Don’t forget to actually go through a basic ROS and get a history!
6. Not ordering the right labs up front
Yes, over-ordering can be a problem. But if you are dealing with a patient with abdominal pain, 9.5/10 times you will need these labs.
Here’s a fast-reference table you can save:
Basic Workup Checklist
| Test | Why It Matters |
| CBC | Infection, bleeding, inflammation |
| CMP | Electrolytes, LFTs, dehydration clues |
| Lipase | Rule out pancreatitis |
| UA | Infection, kidney stones |
| Pregnancy test | Rule out ectopic |
| Imaging (CT/US) | Based on red flags + pain location |
| EKG | Any upper abdominal pain, rule out ACS |
Fix: Order these early — you can always add more based on the story.
7. Misusing imaging (over- or under-ordering)
Over-ordering: CT “just in case” for a patient housing a bag of hot Cheetos → unnecessary radiation + cost.
Under-ordering: Delaying CT when red flags are present (or ordering the wrong type of CT)→ missed “badness”.
Fix:
- RLQ pain: CT with contrast
- RUQ pain: Ultrasound first
- Flank pain: CT without contrast (most places have renal stone protocol)
- Lower abd pain with a uterus: Pelvic ultrasound
- Severe or unclear pain: Don’t wait too long to image
8. Not recognizing the “can’t miss” diagnoses quickly
Here’s a quick reference you can save:
| Diagnosis | Key Clues | What NOT to Miss | First Imaging |
| Appendicitis | RLQ pain, migration, fever | Guarding, rebound | CT with contrast |
| Ectopic pregnancy | Lower abd pain, spotting | Pregnancy? unstable? | Pelvic ultrasound |
| SBO | Vomiting, distension, obstipation | Prior surgeries | CT abdomen/pelvis |
| AAA | Back/abd pain, older adult | Hypotension | CT angiography |
| Mesenteric ischemia | Pain out of proportion | A-fib? vascular disease? | CTA |
| Ovarian torsion | Sudden unilateral pain | Adnexal tenderness | Pelvic US (doppler) |
9. Not asking how the pain is actually affecting them
Patients downplay pain all the time. Sometimes it’s cultural, sometimes they are afraid of the cost of a workup and sometimes it’s simply how they are wired.
Don’t only ask “How bad is the pain?”.
Also ask: “What does the pain keep you from doing?”
If the pain stops them from:
- walking upright
- eating
- sleeping
- working
- taking deep breaths
…you should take it seriously.
10. Forgetting good documentation and discharge instructions
This is where new grads get burned.
Fix: Always include:
- What you think is happening
- What to watch for
- When to return
- Expected course
- When to follow up
Blox can help here — clean return precautions and differentials you can check fast.
Quick Abdominal Pain Framework (Save This)
1. Localize
Upper, lower, RLQ, LLQ, diffuse, flank.
2. Stabilize
Vitals, hydration, antiemetics, pain meds.
3. Screen for the big four
Appendicitis, ectopic, SBO, AAA.
4. Order basics
CBC, CMP, lipase, UA, pregnancy test.
5. Decide imaging
CT vs ultrasound.
6. Re-exam
Pain evolves, so should your plan.
Bottom line: Abdominal pain workups can be overwhelming , but having a repeatable approach makes it a lot easier. Stick to the basics, watch for red flags, and check out Blox for clear differentials, what to order, and what to do next.