AMPLE History Sequence

AMPLE History Sequence

🟢 Lite — Quick Review (1h–1d)

Acute abdomen is sudden, severe abdominal pain demanding urgent surgical or medical evaluation within minutes to hours.

Key clinical signs: Guarding (involuntary muscle rigidity) and rebound tenderness indicate peritoneal irritation. McBurney’s point (1/3 distance from ASIS to umbilicus) is the classic appendicitis tenderness site. Murphy’s sign (inspiratory arrest on RUQ palpation) suggests cholecystitis. Kehr’s sign (left shoulder pain) points to splenic injury or ectopic pregnancy. Psoas sign suggests an inflamed appendix touching the psoas muscle.

Red flag formula: WBC > 18,000/μL with left shift strongly suggests complicated appendicitis.

Alvarado score ≥7 = high probability of surgical appendicitis ( Migration of pain, Anorexia, Nausea/vomiting, Tenderness, Fever, Leukocytosis >10,000, Left shift). Each parameter scores 1 point.

3 exam must-knows: (1) Erect chest X-ray detects free air under the diaphragm — pathognomonic for perforation. (2) Rigid abdomen + absent bowel sounds + tachycardia = surgical emergency. (3) Elderly patients with MI or AAA frequently present with painless or atypical abdominal pain — never exclude surgical causes on history alone.

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🟡 Standard — Regular Study (2d–2mo)

Definition

Acute abdomen encompasses any sudden-onset abdominal condition requiring rapid clinical decision-making, from self-limited gastroenteritis to catastrophic perforation with sepsis. The critical distinction is surgical versus medical cause — misclassification is potentially fatal.

AMPLE History Sequence

Systematically gather: Allergies → Medications → Past medical/surgical history → Last oral intake → Events preceding pain onset. This sequence prevents the common omission of prior abdominal surgeries (risk of adhesion obstruction) or anticoagulant use (bleeding risk).

Physical Examination Priority

Auscultate before palpation to avoid altering bowel sounds. Palpate starting away from the reported pain, assessing for masses, organomegaly, and peritoneal signs. Guarding (voluntary vs. involuntary) differentiates the patient’s defensive response from true peritoneal inflammation. Rebound tenderness confirms parietal peritoneum irritation.

Diagnostic Workup Sequence

1. CBC with differential — leukocytosis with left shift suggests bacterial inflammation
2. Serum amylase/lipase — elevation within 6 hours of symptom onset supports pancreatitis
3. Erect chest X-ray — free subdiaphragmatic air confirms perforation
4. Abdominal X-ray — air-fluid levels indicate obstruction; sentinel loop suggests pancreatitis
5. Focused bedside ultrasound — detects free fluid, gallstones, appendiceal diameter >6mm

Surgical Causes to Recognize

Condition	Classic Feature
Appendicitis	Periumbilical pain migrating to RLQ
Cholecystitis	Murphy’s sign positive
Perforated ulcer	Sudden epigastric pain, rigid abdomen
Bowel obstruction	Colicky pain, distension, vomiting
Diverticulitis	LLQ pain, fever, leukocytosis

Medical Mimics

Myocardial infarction (especially inferior MI), pneumonia, diabetic ketoacidosis, sickle cell crisis, and porphyria all present with abdominal pain — always obtain an ECG in elderly patients.

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🔴 Extended — Deep Study (3mo+)

Pathophysiological Framework

Acute abdomen triggers follow a visceral-somatic pain progression. Initial visceral pain (midline, poorly localized) results from hollow organ distension or capsular stretching. As inflammation reaches the parietal peritoneum, pain becomes somatic, sharper, and more localized. Perforation produces sudden, catastrophic irritation of the entire peritoneal cavity — explaining the classic “pain before vomiting” in appendicitis versus gastroenteritis where vomiting precedes pain.

Advanced Diagnostic Considerations

CT abdomen with contrast (not first-line in unstable patients) achieves 95% sensitivity for appendicitis and detects alternative diagnoses. Diagnostic laparoscopy is both diagnostic and therapeutic for equivocal cases, particularly in women of reproductive age where gynecological pathology overlaps.

Ogilvie syndrome (colonic pseudo-obstruction) occurs post-operatively or in immobilized patients. Criteria: abdominal distension, nausea/vomiting, absent obstipation, and colonic diameter >10cm on imaging without mechanical obstruction. Management escalates from conservative measures to neostigmine (contraindicated in obstruction) to colonoscopic decompression.

Operative Indications

Immediate surgery is mandated for: generalized peritonitis, free perforation with sepsis, strangulated hernia, mesenteric ischemia, and clinical deterioration despite resuscitation. Damage control principles apply to unstable patients — laparotomy with temporary closure, resuscitation in ICU, then definitive repair.

Common Exam Mistakes to Avoid

Mistake 1: Attributing RLQ pain to gastroenteritis without imaging. Up to 20% of appendicitis cases present atypically; normalize WBC does not exclude surgical pathology.

Mistake 2: Inadequate fluid resuscitation before surgery. Hypotensive patients require 2–3L crystalloid before induction to prevent anesthesia-induced cardiovascular collapse.

Mistake 3: Missing torsion. Testicular torsion presents with lower abdominal or inguinal pain — always examine the scrotum in male patients with acute abdomen.

Practice Prompts

1. A 72-year-old man with atrial fibrillation presents with diffuse abdominal pain and vomiting. Exam shows a tender, distended abdomen with no prior surgical history. List your diagnostic priorities and immediate management steps.
2. A 28-year-old woman reports 6 hours of progressive periumbilical pain now localizing to the RLQ, with anorexia, nausea, and a fever of 38.2°C. Her WBC is 14,000 with left shift. Calculate her Alvarado score and justify your management decision.

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