“Something’s wrong with my stomach…”

Abdominal pain is one of the most common but diagnostically challenging complaints in both primary care and emergency settings. From benign to life-threatening, its causes span multiple organ systems, demanding a structured and thorough clinical approach. This mock patient script series helps you sharpen your history taking, physical examination, and clinical reasoning skills for abdominal pain across different settings.

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🩺 Case 1 – The pain started last night, and now I can’t stand up straight.

🚪 Doorway Information

• Age / Gender: 24-year-old male
• Chief Complaint: “Severe abdominal pain that started last night”
• Vital Signs: T 37.9°C / HR 102 / BP 120/70 / RR 18 / SpO₂ 98%

🗣️ Structured History

• Opening: “It started as a dull ache around my belly button.”
• Shoreline: Pain began last night, starting peri-umbilically and gradually shifting to the lower right quadrant. Now persistent and worsening.
• Onset & Course:
  • Started 12 hours ago as mild discomfort
  • Now sharp and localized in the right lower abdomen
  • Worse with movement or coughing
• Associated Symptoms:
  • Mild nausea, no vomiting
  • No diarrhea or constipation
  • No urinary symptoms
• Mood / Function / Appetite / Sleep:
  • Appetite decreased
  • Difficulty sleeping due to pain
• Medical History / Medication:
  • No chronic conditions
  • No medications
• Family & Social History – PAM HITS FOSS:
  • Previous & Past medical history: Unremarkable
  • Allergy: None
  • Medication: None
  • Hospitalization / Injury / Trauma / Surgery: None
  • Family history: Father had gallstones
  • OBGYN: N/A
  • Sexual history: Sexually active, uses condoms
  • Social history: University student, no smoking or drugs, drinks socially
• Concerns & Questions: “Do I need surgery? Will it get worse overnight?”

🩻 Physical Examination

• General appearance: Appears uncomfortable, prefers to lie still, knees drawn up
• Abdomen:
  • Localized tenderness at McBurney’s point
  • Rebound tenderness (Blumberg’s sign): Positive
  • Guarding: Voluntary and mild involuntary guarding
  • Rovsing’s sign: Positive
  • Psoas sign: Positive
  • Obturator sign: Negative
  • Dunphy’s sign: Positive
  • Heel drop test: Positive
• HEENT: No scleral icterus
• Chest: Clear breath sounds, no rales
• Back/CVA tenderness: Absent
• Genital exam: Normal testes, no hernia or torsion
• Neuro: Grossly intact

🩺 Differential Diagnosis (Top 3)

• Most likely diagnosis: Acute Appendicitis
  • Supporting points: Migratory RLQ pain, McBurney’s tenderness, rebound, Rovsing’s sign
  • Contradictory points: No fever, no leukocytosis yet
• 2nd: Mesenteric Adenitis
  • Supporting: Young age, RLQ pain
  • Contradictory: No preceding URI, more focal peritonism
• 3rd: Gastroenteritis
  • Supporting: Nausea and abdominal discomfort
  • Contradictory: No diarrhea, local peritoneal signs

💭 Clinical Reflection

He presents with classic migratory pain and focal peritoneal signs in the RLQ. The absence of systemic signs does not exclude appendicitis. Clinical suspicion remains high, and surgical evaluation should not be delayed while confirming with imaging.

💡 Clinical Pearls

• McBurney’s point tenderness and rebound pain are highly specific.
• Rovsing’s and psoas signs support retrocecal appendicitis.
• Dunphy’s sign and the heel drop test are helpful bedside clues.
• Don’t rely solely on fever or WBC elevation to make the diagnosis.

❓ Challenging Questions

Q1: “Could this just be a stomach bug?”
A: “That’s a possibility, but your symptoms point more toward appendicitis, especially the pain’s location and the signs we found on exam. We’ll confirm with imaging and act quickly if needed.”

Q2: “Will I need surgery today?”
A: “If it is appendicitis, surgery is the standard treatment. We’ll coordinate with the surgical team promptly and keep you informed throughout the process.”

📝 SOAP Note

S: 24-year-old male with 12-hour history of abdominal pain, starting peri-umbilically and migrating to RLQ. Sharp, constant, worse with movement. Mild nausea. No vomiting, diarrhea, or urinary symptoms.

O:
- T 37.9°C, HR 102, BP 120/70, RR 18, SpO₂ 98%
- McBurney’s point tenderness, rebound tenderness, positive Rovsing’s, psoas, Dunphy’s, heel drop signs
- Normal chest, no CVA tenderness

A:
# RLQ abdominal pain with migratory course and peritoneal signs
# Nausea without GI or urinary symptoms
# Young adult with classic appendicitis presentation

ddx): Acute appendicitis, mesenteric adenitis, gastroenteritis  
r/o): Renal colic (no hematuria), torsion (genital exam normal)

→ Acute appendicitis is most likely. Early surgical consultation warranted.

P:
- CBC, CRP, urinalysis
- Abdominal ultrasound or CT (if available)
- NPO, IV fluids, analgesia
- Surgical consultation for appendectomy

📚 References

• UpToDate: Clinical features and diagnosis of acute appendicitis in adults
• Humes DJ, Simpson J. Acute appendicitis. BMJ. 2006;333(7567):530-4. PMID: 16960208
• Hawkins L, et al. Diagnostic accuracy of clinical signs in appendicitis. Ann Emerg Med. 2021. PMID: 33943534

🩺 Case 2 – My belly hurts all the time, but the tests always come back normal.

🚪 Doorway Information

• Age / Gender: 19-year-old female
• Chief Complaint: “Chronic abdominal pain for months”
• Vital Signs: T 36.8°C / HR 76 / BP 112/68 / RR 14 / SpO₂ 99%

🗣️ Structured History

• Opening: “It’s been hurting for months, and no one can find anything wrong.”
• Shoreline: Diffuse, non-radiating abdominal pain ongoing for about 5 months. Seen by multiple doctors, but no clear diagnosis yet.
• Onset & Course:
  • Started gradually about 5 months ago
  • Sometimes worse, sometimes better — no clear pattern
  • Not related to food or bowel movement
• Associated Symptoms:
  • Intermittent nausea
  • No vomiting, diarrhea, constipation, or weight loss
• Mood / Function / Appetite / Sleep:
  • Normal appetite, but eats less during flares
  • Struggles to concentrate at school
  • Sleep is often disturbed by anxiety or pain
• Medical History / Medication:
  • No chronic physical illness
  • Recently started on sertraline by psychiatrist
• Family & Social History – PAM HITS FOSS:
  • Previous & Past medical history: Frequent headaches as a child
  • Allergy: None
  • Medication: Sertraline 25 mg daily
  • Hospitalization / Injury / Trauma / Surgery: None
  • Family history: Mother with IBS, brother with depression
  • OBGYN: Irregular periods, no known gynecologic issues
  • Sexual history: Not currently sexually active
  • Social history: High school student, lives with family, strong academic pressure
• Concerns & Questions: “Is this all in my head? Am I imagining the pain?”

🩻 Physical Examination

• General appearance: Alert, cooperative, looks well
• Abdomen:
  • Soft, non-distended
  • Diffuse mild tenderness, not localized
  • No guarding or rebound
  • Normal bowel sounds
• Carnett’s sign: Positive (pain remains with abdominal wall tensing)
• HEENT: Normal
• Chest: Clear
• Neuro / MSK: Non-focal
• Psychiatric: Mildly anxious affect, good eye contact

🩺 Differential Diagnosis (Top 3)

• Most likely: Functional Abdominal Pain Syndrome (FAPS)
  • Supporting: Chronic pain without organic cause, non-anatomical pattern, Carnett’s sign positive
  • Contradictory: None significant
• 2nd: IBS (Irritable Bowel Syndrome)
  • Supporting: Young woman with abdominal discomfort
  • Contradictory: No change with bowel movements, not meal-related
• 3rd: Somatic Symptom Disorder
  • Supporting: Ongoing symptoms with life impact and emotional burden
  • Contradictory: Not enough features to confirm DSM-5 criteria

💭 Clinical Reflection

Her symptoms and history align with functional abdominal pain syndrome, likely exacerbated by psychological stress. It’s essential to validate her experience, avoid overtesting, and engage a biopsychosocial treatment model.

💡 Clinical Pearls

• Functional pain is real — not imaginary — and often stems from visceral hypersensitivity.
• Carnett’s sign helps differentiate abdominal wall pain from intra-abdominal causes.
• Watch for red flags: weight loss, GI bleeding, persistent fever, family history of IBD or cancer.
• Communication and reassurance are central to management.

❓ Challenging Questions

Q1: “So… does this mean it’s all psychological?”
A: “Not at all. Your pain is real — it’s just that we’re not finding a structural problem on the tests. These symptoms often involve how the brain and gut communicate. We’ll work together to manage it in a way that addresses both body and mind.”

Q2: “Why didn’t the other doctors find anything?”
A: “You’ve already had a thorough workup, which is helpful. The fact that serious conditions have been ruled out gives us more confidence this is a functional condition. That means we can now focus on ways to improve your quality of life and reduce symptoms.”

📝 SOAP Note

S: 19-year-old female with 5-month history of non-specific abdominal pain. Not related to meals or defecation. No systemic symptoms. Distress over lack of diagnosis. History of anxiety, started on sertraline.

O:
- Vitals stable, normal BMI
- Abdomen soft, diffuse tenderness, positive Carnett’s sign
- No masses, no guarding, no rebound
- Psych: Mildly anxious, appropriate behavior

A:
# Chronic abdominal pain without organic findings
# Positive Carnett’s sign
# Psychosocial stressors and emotional burden

ddx): Functional abdominal pain syndrome, IBS, somatic symptom disorder  
r/o): Peptic ulcer (no epigastric pain), IBD (no diarrhea or blood), ovarian (no mass/tenderness)

→ Likely functional abdominal pain. Consider Rome IV criteria and psychological contributors. No further testing needed now.

P:
- Reassurance and education
- Continue sertraline, monitor response
- Referral to psychologist / behavioral therapy
- Symptom diary and lifestyle modification
- Follow-up in 2–3 weeks

📚 References

• Robin SG et al. Functional abdominal pain in children and adolescents. Gastroenterol Clin N Am. 2021. PMID: 35135311
• Drossman DA. The functional gastrointestinal disorders and the Rome IV process. Gastroenterology. 2016. PMID: 27144662
• Chey WD et al. Behavioral therapy in functional GI disorders. Nat Rev Gastroenterol Hepatol. 2015. PMID: 25582992

🩺 Case 3 – It burns after I eat, and I’ve been popping antacids like candy.

🚪 Doorway Information

• Age / Gender: 45-year-old male
• Chief Complaint: “Burning abdominal pain for the past few weeks”
• Vital Signs: T 36.9°C / HR 72 / BP 132/78 / RR 14 / SpO₂ 98%

🗣️ Structured History

• Opening: “I’ve had this burning pain in my stomach that keeps coming back.”
• Shoreline: Epigastric burning pain for 3 weeks, often worse when the stomach is empty. Antacids provide temporary relief.
• Onset & Course:
  • Started insidiously 3 weeks ago
  • Worse at night and a few hours after meals
  • Intermittent but recurring daily
• Associated Symptoms:
  • Some bloating and early satiety
  • No vomiting, no hematemesis or melena
  • No weight loss or fever
• Mood / Function / Appetite / Sleep:
  • Appetite intact, eats smaller meals to avoid discomfort
  • Sleep disturbed by nocturnal pain
• Medical History / Medication:
  • Hypertension, on amlodipine
  • Frequent NSAID use for chronic back pain
• Family & Social History – PAM HITS FOSS:
  • Previous & Past medical history: Chronic low back pain
  • Allergy: None
  • Medication: Amlodipine, OTC ibuprofen, frequent antacids
  • Hospitalization / Injury / Trauma / Surgery: None
  • Family history: Father with peptic ulcer
  • OBGYN: N/A
  • Sexual history: Stable partner, no STI history
  • Social history: Smokes 10 cigarettes/day, drinks 3–4 beers on weekends
• Concerns & Questions: “Is this an ulcer? Could it bleed or get worse?”

🩻 Physical Examination

• General appearance: Comfortable at rest
• Abdomen:
  • Mild tenderness in the epigastric region
  • No rebound or guarding
  • Normal bowel sounds
• Rectal exam: Brown stool, no occult blood (if done)
• HEENT: No pallor
• Neuro / MSK: Normal

🩺 Differential Diagnosis (Top 3)

• Most likely: Duodenal Ulcer (NSAID-induced or H. pylori-related)
  • Supporting: Epigastric pain worse on empty stomach, nocturnal symptoms, NSAID use, antacid-responsive
  • Contradictory: No GI bleeding (yet)
• 2nd: Functional dyspepsia
  • Supporting: Chronic epigastric symptoms without alarm features
  • Contradictory: NSAID use and food-related pattern suggest organic cause
• 3rd: GERD
  • Supporting: Burning epigastric discomfort
  • Contradictory: No reflux or regurgitation, symptoms not meal-induced

💭 Clinical Reflection

His history is strongly suggestive of a duodenal ulcer, likely NSAID-related. H. pylori should be evaluated. While he lacks bleeding or anemia, we must address modifiable risks and consider endoscopy based on guideline criteria.

💡 Clinical Pearls

• Duodenal ulcers often improve with food, unlike gastric ulcers.
• Nighttime pain and relief with antacids are classic features.
• Always ask about NSAID use and test for H. pylori when suspecting peptic ulcers.
• Alarm symptoms (bleeding, weight loss, vomiting) warrant urgent endoscopy.

❓ Challenging Questions

Q1: “Could this turn into cancer?”
A: “Most ulcers are benign, especially duodenal ones. But we do monitor closely and may recommend an endoscopy to be sure. The important thing is identifying the cause and treating it properly — whether it’s H. pylori or NSAIDs.”

Q2: “Will I need a scope?”
A: “In many cases, we can try treatment first if you don’t have alarming symptoms. But if the pain persists or if we find signs like anemia or bleeding, then endoscopy is a good next step. We’ll decide together based on your response to treatment.”

📝 SOAP Note

S: 45-year-old male with 3-week history of burning epigastric pain, worse at night and when fasting. Relief with antacids. Regular NSAID use. No GI bleeding or weight loss.

O:
- Vitals stable
- Epigastric tenderness without rebound or guarding
- Rectal exam normal, no melena
- No anemia or systemic symptoms

A:
# Suspected duodenal ulcer, likely NSAID-related
# Risk factors: NSAID use, smoking, possible H. pylori
# No alarm symptoms but nighttime pain present

ddx): Duodenal ulcer, functional dyspepsia, GERD  
r/o): Gastric malignancy (no weight loss, no anemia), pancreatitis (no back pain, normal enzymes)

→ Likely duodenal ulcer. Consider test-and-treat strategy for H. pylori or empiric PPI.

P:
- H. pylori stool antigen or urea breath test
- Stop NSAIDs, start PPI (e.g. omeprazole)
- Smoking and alcohol counseling
- Consider endoscopy if symptoms persist or worsen
- Follow-up in 2–4 weeks

📚 References

• Chey WD et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017. PMID: 28445666
• Laine L et al. Approaches to NSAID-associated ulcer prevention. N Engl J Med. 2008. PMID: 18354104
• UpToDate: Clinical manifestations and diagnosis of peptic ulcer disease

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🧾 Article Summary

This article presented three representative cases of abdominal pain: an acute surgical emergency (appendicitis), a functional pain syndrome with no organic cause, and an ulcer-related case driven by modifiable risk factors. These cases aim to strengthen your clinical reasoning in abdominal pain scenarios, whether acute or chronic, organic or functional.

• Case 1: Sharp migratory pain with rebound → Think Acute Appendicitis
• Case 2: Chronic diffuse pain with normal tests → Consider Functional Abdominal Pain Syndrome
• Case 3: Burning epigastric pain, worse when fasting → Evaluate for Duodenal Ulcer

Each case highlights different facets of abdominal pain and emphasizes the importance of clinical context, psychosocial history, and red flags for serious conditions.

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🔎 Differential Diagnosis List – VITAMIN CDE Framework

• V – Vascular: Mesenteric ischemia, AAA rupture
• I – Infectious / Inflammatory: Appendicitis, diverticulitis, gastroenteritis, PID, cholecystitis, pancreatitis, hepatitis
• T – Trauma: Splenic rupture, organ contusion, post-surgical complications
• A – Autoimmune / Allergic: IBD (Crohn’s, UC), vasculitis, celiac disease
• M – Metabolic / Endocrine: DKA, hypercalcemia, Addisonian crisis, porphyria
• I – Idiopathic / Iatrogenic: Functional abdominal pain, medication side effects (NSAIDs, opioids)
• N – Neoplastic: Colorectal cancer, pancreatic cancer, GIST, lymphoma
• C – Congenital / Structural: Meckel’s diverticulum, hernias, malrotation
• D – Degenerative / Deficiency: Constipation due to immobility or fiber deficiency
• E – Endocrine / Psychogenic: Anxiety-related GI symptoms, somatic symptom disorder, depression

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🔗 Related Articles

• 🔎 Symptom-based approach to Abdominal Pain
• ⚖️ Unintentional Weight Loss
• 🤢 Nausea and Vomiting
• 🥣 Loss of Appetite
• 🚽 Diarrhea / Constipation

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📚 References

• UpToDate. Clinical approach to abdominal pain. [Accessed 2025]
• Chey WD et al. ACG Guideline: H. pylori infection. Am J Gastroenterol. 2017. PMID: 28445666
• Drossman DA. Rome IV functional GI disorders. Gastroenterology. 2016. PMID: 27144662
• Laine L et al. NSAID-related ulcers. N Engl J Med. 2008. PMID: 18354104