Abdominal & headache presentations

RUQ – Right Upper Quadrant

Think: liver, gallbladder, diaphragm

• Cholecystitis
  RUQ ± epigastric → right shoulder/scapula (phrenic nerve irritation), worse after fatty meals, Murphy’s sign.

• Biliary colic
  RUQ pain that comes in waves, usually settles within hours, no fever (unlike cholecystitis).

• Hepatitis
  RUQ discomfort + systemic symptoms (malaise, jaundice, dark urine).

• Liver abscess
  RUQ pain + sepsis picture, referred shoulder pain, often febrile.

• Right lower lobe pneumonia
  RUQ pain via diaphragmatic irritation, respiratory signs may be subtle.

RLQ – Right Lower Quadrant

Think: appendix, terminal ileum, gynae

• Appendicitis
  Starts periumbilical (visceral midgut pain) → migrates to RLQ (McBurney’s point) as parietal peritoneum becomes inflamed.

• Mesenteric adenitis
  RLQ pain + recent viral illness, often younger patients, mimics appendicitis.

• Crohn’s disease flare
  RLQ pain (terminal ileum), chronic history, weight loss, diarrhoea.

• Ectopic pregnancy
  RLQ or suprapubic pain + amenorrhoea, bleeding, haemodynamic instability.

• Ovarian torsion
  Sudden severe unilateral lower abdominal pain, nausea/vomiting.

LUQ – Left Upper Quadrant

Think: spleen, stomach, pancreas (tail)

• Splenic injury / rupture
  LUQ pain → left shoulder (Kehr’s sign), trauma or atraumatic rupture (EBV).

• Gastritis / peptic ulcer disease
  Epigastric/LUQ burning pain, worse with food or NSAIDs.

• Pancreatitis (can extend LUQ)
  Epigastric → straight through to back, relieved by leaning forward.

• Left lower lobe pneumonia
  LUQ or epigastric pain with respiratory features.

LLQ – Left Lower Quadrant

Think: sigmoid colon, gynae

• Diverticulitis
  Constant LLQ pain, localised tenderness, fever ± bowel habit change.

• Constipation / faecal loading
  LLQ discomfort, bloating, reduced bowel motions.

• Ischaemic colitis
  LLQ pain + bloody diarrhoea, older patients, vascular risk factors.

• Ovarian pathology (cyst/torsion)
  Unilateral LLQ pain, sudden onset if torsion.

Appendicitis

Mechanism: Obstruction of appendix → inflammation → possible perforation.

Classic presentation

• Periumbilical pain → migrates to RLQ

• McBurney’s point tenderness

• Pain before nausea

• Anorexia

• Fever (often low-grade)

• Rebound/percussion tenderness

• Worse with movement, coughing, heel-drop

• Guarding

May also see

• Rovsing’s sign (LLQ palpation → RLQ pain)

• Psoas sign (retrocaecal appendix)

• Tachycardia

Red flags

• Sudden pain relief → then worsening → possible perforation

Renal Colic (Kidney Stone)

Mechanism: Ureter obstruction causing smooth muscle spasm.

Classic presentation

• Severe colicky/wave-like flank pain

• Radiates flank → groin

• Restless patient (moves around)

• Haematuria

• Urinary urgency/frequency

• Nausea/vomiting

• CVA tenderness

May also see

• Testicular/labial referred pain

• Sweating

Less likely

• Fever (unless infected)

Pyelonephritis (Kidney Infection)

Mechanism: Ascending UTI causing renal infection.

Classic presentation

• Fever ± rigors

• Flank pain

• CVA tenderness

• Dysuria

• Frequency

• Nausea/vomiting

May also see

• Sepsis signs

• Tachycardia

• Malaise

Peritonitis

Mechanism: Irritation/inflammation of peritoneum.

Classic presentation

• Patient lies very still

• Pain worse with movement

• Guarding → rigidity

• Rebound tenderness

• Fever

• Distension

• Reduced bowel sounds

May also see

• Heel-drop positive

• Sepsis

Abdominal Aortic Aneurysm (AAA)

Mechanism: Aortic dilation ± rupture.

Classic presentation

• Abdominal/back pain

• Syncope/near syncope

• Hypotension

• Pulsatile mass

• BP difference

• Sudden onset

May also see

• Grey, sweaty appearance

• Flank bruising (late)

High risk

• Older age

• Smoking

• Hypertension

Ectopic Pregnancy

Mechanism: Pregnancy outside uterus (usually tube).

Classic presentation

• Pelvic/lower abdo pain

• Vaginal bleeding

• Missed period

• Shoulder tip pain

• Syncope

• Pregnancy possible

Risk factors

• Previous ectopic

• IVF

• PID

Red flags

• Shock with minimal bleeding

Diverticulitis

Mechanism: Inflamed diverticula.

Classic presentation

• LLQ pain

• Fever

• Change in bowel habit

• Localised tenderness

May also see

• Nausea

• Urinary symptoms

Pancreatitis

Mechanism: Pancreatic inflammation.

Classic presentation

• Severe epigastric pain

• Radiates to back

• Better sitting forward

• Worse after eating

• Vomiting

Risk factors

• Alcohol

• Gallstones

May also see

• Fever

• Grey Turner/Cullen signs (late)

Cholecystitis / Biliary Colic

Mechanism: Gallbladder inflammation/obstruction.

Classic presentation

• RUQ pain

• Murphy’s sign

• Worse after fatty food

• Nausea/vomiting

• Referred shoulder/scapula pain

May also see

• Fever

• Guarding

Biliary Obstruction / Cholangitis

Mechanism: Blocked bile flow ± infection.

Classic presentation

• RUQ pain

• Jaundice

• Pale stool

• Dark urine

If cholangitis

• Fever + RUQ pain + jaundice (Charcot triad)

Red flags

• Hypotension/confusion (Reynolds pentad)

Mesenteric Ischaemia

Mechanism: Reduced bowel blood flow.

Classic presentation

• Pain out of proportion to exam

• Severe diffuse pain

• Vomiting

• AF history

• Recent vascular disease

May also see

• Blood in stool (late)

• Minimal tenderness initially

Bowel Obstruction

Mechanism: Mechanical/functional bowel blockage.

Classic presentation

• Colicky pain

• Distension

• Vomiting

• Constipation

• No flatus

Exam

• High-pitched bowel sounds early

• Absent bowel sounds late

Colitis

Mechanism: Colon inflammation (infectious/IBD/ischaemic).

Classic presentation

• Cramping pain

• Diarrhoea

• Blood/mucus in stool

• Fever

May also see

• Urgency

• Tenesmus

Gastroenteritis

Mechanism: GI infection.

Classic presentation

• Vomiting

• Diarrhoea

• Cramping

• Fever

Risk factors

• Travel

• Recent antibiotics

• Sick contacts

GI Bleed (Upper vs Lower)

Upper

• Coffee-ground vomit

• Melaena

• NSAID history

Lower

• Frank red blood

• Diverticular disease

• Colitis

Red flags

• Syncope

• Shock

Urinary Retention / Prostatic Obstruction

Mechanism: Inability to empty bladder.

Classic presentation

• Suprapubic fullness

• Need to urinate but unable

• Frequency

• Lower abdo pain

Risk factors

• BPH

• Anticholinergics

Ovarian/Testicular Torsion

Mechanism: Twisting causing ischaemia.

Classic presentation

• Sudden severe pain

• Tender

• High-riding testicle (testicular)

• Nausea/vomiting

Red flag

• Time critical

52-year-old female

• Upper abdominal pain

• Worse after dinner

• Nausea

• Tender under right ribs

• Murphy’s sign (+) → Cholecystitis

• Jaundice (+) → Bile duct obstruction / cholangitis / choledocholithiasis

• Dark urine (+) → Conjugated bilirubin → obstructive jaundice

• Pale stool (+) → Reduced bile entering bowel → biliary obstruction

• Fever (+) → Inflammatory/infective process → cholecystitis or cholangitis

• Shoulder/scapula pain (+) → Diaphragmatic irritation → gallbladder pathology

• Back radiation (+) → Consider pancreatitis

• Rebound/guarding (+) → Peritoneal irritation → severe inflammation/perforation

• Most likely → Cholecystitis

31-year-old male

• Sudden left flank pain

• Radiates downward

• Vomiting

• Restless

• CVA tenderness (+) → Renal source (stone / pyelonephritis)

• Haematuria (+) → Kidney stone

• Fever (+) → Pyelonephritis / infected obstruction

• Dysuria/frequency (+) → UTI involvement

• Pain radiates to groin (+) → Ureteric stone

• Pulsatile mass (+) → AAA

• Patient lies still → Peritonitis more likely than stone

• Patient pacing/restless → Colicky obstruction

• Most likely → Renal colic

18-year-old

• Pain started central

• Now RLQ

• Doesn’t want to move

• McBurney’s (+) → Appendicitis

• Heel-drop (+) → Peritoneal irritation

• Rebound (+) → Peritoneal irritation

• Guarding (+) → Inflammation progressing

• Pain before nausea (+) → Supports appendicitis

• Fever (+) → Inflammatory/infective process

• Generalised tenderness (+) → Possible perforation

• Most likely → Appendicitis

64-year-old

• Severe abdominal pain

• Minimal tenderness

• AF history

• Pain out of proportion (+) → Mesenteric ischaemia

• Blood in stool (+) → Bowel injury/ischaemia

• AF history (+) → Embolic source

• Distension (+) → Advanced bowel compromise

• Hypotension (+) → Late/critical disease

• Lactate elevated (+) → Poor perfusion/ischaemia

• Most likely → Mesenteric ischaemia

46-year-old

• Vomiting

• Epigastric Pain

• Leaning forward helps

• Back radiation (+) → Pancreatitis

• Improves sitting forward (+) → Pancreatitis

• Recent alcohol (+) → Alcohol pancreatitis

• Murphy’s (+) → Gallstone pancreatitis possibility

• Guarding/rebound (+) → Peritoneal irritation

• Grey Turner (+) → Retroperitoneal bleeding → severe pancreatitis

• Cullen’s (+) → Haemorrhagic pancreatitis

Most likely → Pancreatitis

Subarachnoid Haemorrhage (SAH)

• Thunderclap headache → strongly supports SAH

• Maximum intensity instantly

• “Worst headache of life”

• Collapse/LOC at onset

• Neck pain/stiffness

• Nausea/vomiting

• Recent exertion/sex

• Known aneurysm

• Anticoagulants

• Seizure

• Photophobia

Less supportive

• Similar to previous migraines

Stroke

Think: sudden bleed → raised ICP + meningeal irritation

Findings

• Weakness

• Facial droop

• Speech difficulty

• Vision change

• Numbness

• Ataxia

• Confusion

• Dizziness

• Sudden onset

• Last known normal important

Posterior stroke clues

• Vertigo

• Ataxia

• Visual disturbance

• Vomiting

Meningitis / Encephalitis

Think: infection + meningeal irritation ± brain dysfunction

• Fever

• Neck stiffness

• Photophobia

• Altered mental state

• Recent infection

• Rash

• Seizure

• Immunocompromised

• IV drug use

• Vomiting

More encephalitis

• Confusion

• Personality change

• Seizure

Acute Angle Closure Glaucoma (AACG)

Think: painful eye causing headache

Findings

• One-sided eye pain

• Blurred vision

• Halos around lights

• Previous glaucoma

• Red eye

• Nausea/vomiting

• Fixed/mid-dilated pupil (extra)

Migraine

Think: recurrent neurovascular headache

Findings

• Similar to previous

• History of migraines

• Aura

• Triggers

• Photophobia

• Nausea/vomiting

• Hormonal link

Less supportive

• Focal neuro deficits that persist

• Fever

• Neck stiffness

Raised ICP / Mass Lesion

Think: pressure building over time

Findings

• Worse in morning

• Worse lying flat

• Vomiting without nausea

• Personality change

• Cancer history

• Bradycardia

• Wide pulse pressure

• Visual disturbance

• Reduced GCS

Red flag

• Cushing response → bradycardia + hypertension

Temporal Arteritis (Giant Cell Arteritis)

Think: vascular inflammation

Findings

• New unilateral temporal headache

• Age >50

• Scalp tenderness

• Jaw pain when chewing

• Vision disturbance

• Low-grade fever

• Shoulder/hip pain

Red flag

• Vision loss

48-year-old

• Sudden severe headache

• Vomited once

• Says it hit instantly

Further assessment → interpretation

• Neck stiffness (+) → SAH / meningitis

• Collapse at onset (+) → SAH

• Recent exertion/sex (+) → SAH

• Known aneurysm (+) → SAH

• Weakness (+) → stroke

• Anticoagulants (+) → intracranial bleed

Most likely → Subarachnoid haemorrhage

67-year-old

• New headache

• Says scalp hurts

• Complains eating hurts

Further assessment → interpretation

• Jaw pain chewing (+) → temporal arteritis

• Vision symptoms (+) → temporal arteritis (urgent)

• Age >50 (+) → supports GCA

• Shoulder stiffness (+) → polymyalgia rheumatica association

• Fever (+) → inflammatory cause

Most likely → Temporal arteritis

22-year-old

• Headache

• Fever

• Feels “foggy”

Further assessment → interpretation

• Photophobia (+) → meningitis

• Neck stiffness (+) → meningeal irritation

• Rash (+) → meningococcal concern

• AMS (+) → encephalitis

• Recent infection (+) → infectious cause

Most likely → Meningitis / encephalitis

38-year-old

• Headache

• One eye hurts

• Vomited

Further assessment → interpretation

• Red eye (+) → AACG

• Blurred vision (+) → raised ocular pressure

• Halos (+) → AACG

• Previous glaucoma (+) → AACG

• Dilated pupil (+) → AACG

Most likely → Acute angle closure glaucoma

55-year-old

• Headache worse mornings

• Vomits but not nauseated

Further assessment → interpretation

• Worse lying flat (+) → raised ICP

• Visual disturbance (+) → raised ICP

• Personality change (+) → frontal lesion

• Bradycardia (+) → raised ICP

• Cancer history (+) → mass lesion

Most likely → Raised ICP / intracranial mass