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dx.
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I know the diagnosis
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Fractures & dislocations
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Drug reference
Calculators
Clinical calculators
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Billing code lookup
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Interpretation guide
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Abdominal Pain, Undifferentiated
Resuscitation and Universal Approaches
Approach to Unresponsive Patient
Approach to Airway Obstruction And Stridor
Approach to Acute Respiratory Distress With Impending Failure
Approach to Peri-arrest Hypotension
Approach to Post Resuscitation Care After Rosc
Approach to Cardiac Arrest Rhythms, Pea, Asystole
Approach to Cardiac Arrest Rhythms, Vf, Pulseless Vt
Approach to Severe Agitation With Safety Risk
Approach to Procedural Sedation
Chest and Cardiovascular
Approach to Pacemaker And Icd Related Presentations
Approach to Acute Limb Ischemia And Leg Pain
Approach to Suspected Deep Vein Thrombosis Symptoms
Approach to Hypertension
Approach to Chest Pain
Approach to Palpitations And Tachyarrhythmia Symptoms
Approach to Bradycardia Symptoms
Approach to Syncope And Presyncope
Approach to Syncope With Neurologic Concern
Approach to Unilateral Leg Swelling
Approach to Bilateral Leg Swelling
Approach to Calf Pain And Swelling
Respiratory
Approach to Wheezing, Undifferentiated
Approach to Wheezing In Infants
Approach to Stridor And Upper Airway Symptoms
Approach to Dyspnea
Approach to Aspiration Event
Approach to Cough
Approach to Hemoptysis
Approach to Upper Respiratory Infection Symptoms
Approach to Suspected Pulmonary Embolism Presentation
Approach to Smoke Inhalation Concern
Approach to Smoke Exposure And Inhalational Injury
Abdominal and Gastrointestinal
Approach to Abdominal Distension
Approach to Abdominal Pain, Undifferentiated
Approach to Acute Abdominal Pain (general)
Approach to Suspected Incarcerated Or Strangulated Hernia
Approach to Pancreatitis Concern
Approach to Biliary Colic And Cholecystitis Concern
Approach to Appendicitis Concern
Approach to Diverticulitis Concern
Approach to Rectal Pain And Anorectal Complaints
Approach to Dysphagia And Food Bolus Impaction
Approach to Foreign Body Ingestion
Approach to Refractory Vomiting And Recurrent Vomiting Syndromes
Approach to Cannabis Associated Hyperemesis
Approach to Upper Gastrointestinal Bleeding Symptoms (melena)
Approach to Lower Gastrointestinal Bleeding And Hematochezia
Approach to Constipation And Obstipation
Approach to Diarrhea
Approach to Acute Hepatitis And Jaundice Concern
Approach to Right Upper Quadrant Pain
Approach to Epigastric Pain
Approach to Left Upper Quadrant Pain
Approach to Right Lower Quadrant Pain
Approach to Left Lower Quadrant Pain
Approach to Suprapubic Pain
Renal and Urinary
Approach to Oliguria And Anuria
Approach to Catheter Related Urinary Complaints
Approach to Dialysis Patient Presentations
Approach to Flank Pain And Renal Colic Concern
Approach to Urinary Retention
Approach to Hematuria
Approach to Scrotal Pain
Neurologic
Approach to Transient Neurologic Deficits
Approach to Acute Aphasia And Speech Disturbance
Approach to Acute Confusion And Delirium
Approach to Postictal State And Seizure Recurrence Concern
Approach to Seizure
Approach to Acute Vision Loss
Approach to New Tremor And Involuntary Movements
Approach to Headache
Approach to Vertigo
Approach to Acute Weakness Or Numbness
Approach to Gait Instability And Ataxia
Back and Neck
Approach to Atraumatic Back Pain
Approach to Sciatica And Radicular Back Pain
Approach to Back Pain With Neurologic Deficit, Cauda Equina Concern
Approach to Back Pain With Fever Or Immunosuppression, Spinal Infection Concern
Approach to Atraumatic Neck Pain
Approach to Neck Pain After Trauma
Approach to Neck Pain With Meningismus Concern
Approach to Acute Torticollis
Women's Health, Pregnancy, and GU
Approach to Vaginal Discharge
Approach to Hyperemesis Gravidarum Concern
Approach to Hypertensive Disorders Of Pregnancy Symptoms
Approach to Postpartum Hemorrhage Concern
Approach to Postpartum Infection Concern
Approach to Sexual Assault Medical Evaluation Overview
Approach to Pelvic Pain
Approach to Vaginal Bleeding, Nonpregnant
Approach to Vaginal Bleeding In Pregnancy
Approach to Pelvic Pain In Pregnancy
Approach to Post Procedure Or Post Abortion Complications Concern
Infectious Disease and Fever Syndromes
Approach to Fever In The Immunocompromised Patient
Approach to Fever With Rash
Approach to Animal Bites And Rabies Risk Assessment
Approach to Tick Exposure And Tick Borne Illness Concern
Approach to Sepsis Concern Without Clear Source
Approach to Soft Tissue Infection Concern
Approach to Abscess And Skin Infection Concern
Approach to Sore Throat
Approach to Sore Throat And Pharyngitis Symptoms
Approach to Meningitis
Approach to Envenomation And Bites
Allergy and Dermatology
Approach to Pruritus Without Rash
Approach to Contact Dermatitis And Eczema Flare
Approach to Herpes Zoster Concern
Approach to Drug Eruption Concern And Severe Cutaneous Reaction Red Flags
Approach to Urticaria
Approach to Angioedema Concern
Approach to Unexplained Bruising Or Bleeding Symptoms
Musculoskeletal and Extremities
Approach to Shoulder Pain
Approach to Elbow Pain
Approach to Wrist Pain
Approach to Hand Pain
Approach to Hip Pain
Approach to Knee Pain
Approach to Ankle Pain
Approach to Foot Pain
Approach to Cast Or Splint Complication Symptoms
Approach to Wound Check And Suture Related Visits
Approach to Joint Swelling And Monoarthritis
Approach to Suspected Septic Joint Presentation
Approach to Suspected Tendon Rupture Presentation
Approach to Limp Or Refusal To Bear Weight
Trauma and Wounds
Approach to Motor Vehicle Collision Evaluation
Approach to Chest Wall Trauma And Rib Injury
Approach to Blunt Abdominal Trauma Evaluation
Approach to Penetrating Trauma Evaluation
Approach to Pediatric Minor Head Trauma
Approach to Pediatric Head Trauma
Approach to Facial Lacerations And Dental Trauma
Approach to Hand Lacerations With Tendon Injury Concern
Approach to Puncture Wounds And Retained Foreign Body Concern
Approach to Electrical Injury
Approach to Burn Injury
Approach to Fall Evaluation
Approach to Assault And Interpersonal Violence Evaluation
Approach to Eye Trauma And Hyphema Concern
ENT, Eye, Dental
Approach to Dysphagia And Odynophagia
Approach to Throat Pain
Approach to Ear Pain
Approach to Foreign Body In Ear Or Nose
Approach to Vision Loss Complaint
Approach to Flashes And Floaters
Approach to Atraumatic Eye Pain
Approach to Red Eye
Approach to Dental Abscess Concern
Approach to Post Extraction Pain And Complications
Endocrine, Metabolic, and Abnormal Labs
Approach to Hyperglycemia
Approach to Hypoglycemia
Approach to Hyponatremia Symptoms
Approach to Hyperkalemia Symptoms
Approach to Hypokalemia Symptoms
Approach to Rhabdomyolysis Concern
Approach to Anticoagulation Related Abnormal Coagulation Studies
Approach to Acute Kidney Injury And Elevated Creatinine Referral
Approach to Symptomatic Anemia Concern
Toxicology and Behavioral
Approach to Undifferentiated Overdose
Approach to Opioid Toxicity
Approach to Opioid Withdrawal
Approach to Alcohol Intoxication
Approach to Alcohol Withdrawal
Approach to Stimulant Toxicity
Approach to Pediatric Ingestion
Approach to Carbon Monoxide Exposure
Approach to Inhalational Or Chemical Exposure
Approach to Suicidal Ideation And Self Harm Risk Assessment
Approach to Acute Psychosis And Mania Symptoms
Approach to Anxiety And Panic Symptoms
Approach to Capacity Assessment And Safe Disposition
Approach to Behavioral Escalation And Restraint Considerations
Pediatrics
Approach to Fever In The Neonate And Young Infant
Approach to Pediatric Fever By Age 0 To 28 Days
Approach to Pediatric Fever By Age 29 To 60 Days
Approach to Pediatric Fever By Age 2 To 24 Months
Approach to Pediatric Respiratory Distress
Approach to Croup And Stridor In Children
Approach to Pediatric Dehydration
Approach to Pediatric Abdominal Pain
Approach to Febrile Seizure
Approach to Rash In The Child
Approach to Poor Feeding And Lethargy In The Infant
Approach to Vomiting In The Child
Approach to Diarrhea In The Child
Approach to Pediatric Trauma Evaluation
Approach to Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern
Approach to Lethargy And Altered Mental Status In The Child
Environmental and Exposure
Approach to Heat Illness
Approach to Hypothermia And Cold Exposure
Approach to Frostbite Concern
Approach to Drowning And Submersion Injury
Abdominal Pain, Undifferentiated
POCUS
Procedures
Medications
Calculators
Resuscitation
ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
History
HPI overview
Symptom context and trajectory
▶
Time of onset and duration
Course pattern
Constant
Intermittent
Progressive
Triggers and precipitating events
Baseline status and prior similar episodes
OPQRST
O onset
▶
Sudden
Gradual
Maximal at onset
Post prandial onset
Post exertional onset
P provocation and palliation
▶
Worse with movement
Worse with eating
Worse with inspiration
Relief with vomiting
Relief with bowel movement
Relief with antacids
Q quality
▶
Cramping
Sharp
Dull
Burning
Colicky
Tearing
R region and radiation
▶
Epigastric
Right upper quadrant
Right lower quadrant
Left lower quadrant
Suprapubic
Flank
Radiation to back
Radiation to shoulder
Radiation to groin
S severity
▶
Peak severity
Current severity
Function limiting
T timing
▶
Time course
Frequency
Relation to meals
Nocturnal symptoms
Associated symptoms
GI associated symptoms
▶
Nausea
Vomiting
Hematemesis
Diarrhea
Constipation
Obstipation
Melena
Hematochezia
Anorexia
GU and reproductive associated symptoms
▶
Dysuria
Frequency
Hematuria
Vaginal bleeding
Vaginal discharge
Testicular pain
Systemic associated symptoms
▶
Fever
Chills
Weight loss
Syncope
Dyspnea
High yield context
Exposures and events
▶
Recent travel
Sick contacts
Foodborne exposure
Recent antibiotics
Recent procedures
Special populations
▶
Pregnancy possibility
Older adult frailty
Immunocompromised status
Anticoagulation
Alarm Features
Immediate escalation triggers
Resuscitation criteria
▶
Systolic blood pressure less than 90 mmHg
Mean arterial pressure less than 65 mmHg
Heart rate greater than 130 per minute
Respiratory rate greater than 30 per minute
Oxygen saturation less than 90 percent on room air
Altered mental status
Signs of shock
Peritonitis and surgical abdomen
High risk exam findings
▶
Rebound tenderness
Guarding
Rigidity
Involuntary guarding
Severe localized tenderness with percussion pain
Hemorrhage and ischemia red flags
High risk symptoms
▶
Hematemesis
Melena
Hematochezia with hemodynamic changes
Pain out of proportion to exam
Sudden severe abdominal pain
Syncope with abdominal pain
Pregnancy related red flags
Ectopic risk features
▶
Positive pregnancy test with abdominal pain
Shoulder tip pain
Syncope or presyncope
Adnexal tenderness or mass
Infection and sepsis red flags
High risk features
▶
Fever with hypotension
Rigors with tachycardia
Immunocompromised with abdominal pain
Severe pain with lactate elevation
Medications
Medication reconciliation
Current medication list
▶
Prescription medications
Over the counter medications
Supplements and herbals
Recent medication changes
Medication risks for abdominal pain
High risk classes
▶
NSAIDs
Anticoagulants
Antiplatelets
Opioids
GLP 1 receptor agonists
Steroids
Chemotherapy or immunotherapy
Medication interaction and contraindication traps
Common ED therapy conflicts
▶
NSAIDs with chronic kidney disease
NSAIDs with anticoagulation
QT prolonging antiemetics with prolonged QTc
Opioids with severe hypercapnia risk
Diet
Intake and hydration pattern
Recent intake
▶
Poor oral intake
Last meal timing
Trigger foods
High fat meals
Spicy foods
Hydration status indicators
▶
Reduced fluids
Oliguria
Orthostasis symptoms
Substance exposure
Alcohol exposure
▶
Recent binge
Daily heavy use
Caffeine and energy drinks
▶
High intake
Recent increase
Review of Systems
GI
GI symptoms
▶
Dysphagia
Odynophagia
Early satiety
Bloating
Jaundice
Cardiopulmonary
Cardiopulmonary symptoms
▶
Chest pain
Dyspnea
Palpitations
Pleuritic pain
Neuro
Neuro symptoms
▶
Syncope
Focal weakness
Severe headache
Constitutional and infection
Systemic symptoms
▶
Fever
Chills
Night sweats
Collateral History and Family History
Collateral and reliability
Collateral source
▶
Family member
Caregiver
Paramedics
Facility staff
Family history
High yield inherited or familial conditions
▶
Early coronary artery disease
Inflammatory bowel disease
Colorectal cancer
Abdominal aortic aneurysm
Household and exposure context
Shared exposures
▶
Sick contacts
Food exposures
Travel companions symptoms
Risk Factors
Thrombotic and vascular risk
Mesenteric ischemia risk
▶
Atrial fibrillation
Known peripheral arterial disease
Recent arterial catheterization
Hypercoagulable state
Surgical and obstruction risk
Adhesion and obstruction risk
▶
Prior abdominal surgery
Hernia history
Malignancy
Infectious risk
Elevated infection risk
▶
Immunosuppression
Diabetes mellitus (E11.9)
Cirrhosis (K74.60)
Pregnancy and gynecologic risk
Ectopic and pelvic infection risk
▶
Prior ectopic pregnancy (O00)
Prior tubal surgery
Current IUD
Prior pelvic inflammatory disease (N73.9)
Medication and toxin risk
Exposure risks
▶
NSAID use
Alcohol use
Cocaine or stimulant use
Differential Diagnosis
Life threatening
Cannot miss diagnoses
▶
Ruptured abdominal aortic aneurysm (I71.4)
▶
Hypotension or syncope
Back or flank pain
Older age or vascular disease
Mesenteric ischemia (K55.9)
▶
Pain out of proportion to exam
Atrial fibrillation or vascular disease
Metabolic acidosis or lactate elevation
Perforated viscus (K63.1)
▶
Sudden severe pain
Peritonitis
Free air on imaging
Bowel obstruction with strangulation (K56.60)
▶
Severe pain with peritonitis
Fever and tachycardia
Leukocytosis or lactate elevation
Sepsis from intra abdominal source (A41.9)
▶
Hypotension
Altered mental status
Lactate elevation
Ectopic pregnancy (O00)
▶
Positive pregnancy test
Vaginal bleeding
Syncope or shoulder tip pain
Cannot miss in this population
High risk subgroup diagnoses
▶
Acute coronary syndrome atypical (I21.9)
▶
Epigastric discomfort
Risk factors for coronary disease
Abnormal ECG or troponin
Testicular torsion (N44)
▶
Lower abdominal pain with testicular symptoms
Absent cremasteric reflex
High riding testis
Ovarian torsion (N83.5)
▶
Sudden unilateral pelvic pain
Nausea and vomiting
Adnexal mass risk
Common
Common ED diagnoses
▶
Appendicitis (K35.80)
▶
Migration to right lower quadrant
Anorexia
Localized tenderness
Cholecystitis (K81.0)
▶
Right upper quadrant pain
Fever
Murphy sign
Biliary colic (K80.20)
▶
Post prandial right upper quadrant pain
Afebrile
Normal inflammatory markers
Acute pancreatitis (K85.9)
▶
Epigastric pain radiating to back
Lipase elevation
Alcohol or gallstone risk
Gastroenteritis (A09)
▶
Vomiting
Diarrhea
Sick contacts
Renal colic ureterolithiasis (N20.1)
▶
Flank to groin pain
Hematuria
Colicky pattern
Urinary tract infection (N39.0)
▶
Dysuria
Frequency
Pyuria
Constipation (K59.00)
▶
Decreased stool frequency
Hard stools
Relief after bowel movement
Less common and zebras
Less common diagnoses
▶
Diverticulitis (K57.92)
▶
Left lower quadrant pain
Fever
Leukocytosis
Inflammatory bowel disease flare (K50.90)
▶
Chronic diarrhea
Weight loss
Extra intestinal symptoms
Hepatitis (K75.9)
▶
Jaundice
Marked transaminase elevation
Risk exposures
Small bowel obstruction (K56.609)
▶
Vomiting
Abdominal distension
Obstipation
Herpes zoster prodrome (B02.9)
▶
Dermatomal pain
Rash later
Hyperesthesia
Mimics and pitfalls
Mimics
▶
Abdominal wall pain
▶
Localized tenderness
Worse with tensing abdominal muscles
Diabetic ketoacidosis (E10.10)
▶
Nausea and vomiting
Abdominal pain
Anion gap metabolic acidosis
Lower lobe pneumonia (J18.9)
▶
Cough
Pleuritic pain
Abnormal lung exam
Past Medical History
Relevant conditions and procedures
Relevant diagnoses
▶
Peptic ulcer disease (K27.9)
Gallstones (K80.20)
Chronic kidney disease (N18.9)
Diabetes mellitus (E11.9)
Atrial fibrillation (I48.91)
Prior abdominal aortic aneurysm (I71.4)
Prior surgeries and procedures
▶
Appendectomy
Cholecystectomy
Bariatric surgery
Bowel surgery
Prior hospitalizations and ICU
▶
Prior sepsis
Prior bowel obstruction
Physical Exam
General and vitals interpretation
Clinical appearance
▶
Toxic appearing
Diaphoretic
Ill appearing
Comfortable at rest
Hemodynamic profile
▶
Hypotension pattern
Tachycardia pattern
Orthostatic changes
Abdominal exam
Abdominal findings
▶
Focal tenderness location
Diffuse tenderness
Guarding
Rebound tenderness
Rigidity
Distension
Bowel sounds decreased
Targeted maneuvers
▶
Murphy sign
Rovsing sign
Psoas sign
Obturator sign
Carnett sign
Cardiopulmonary and vascular
Cardiopulmonary exam
▶
Heart sounds and murmurs
Lung crackles
Focal decreased breath sounds
Peripheral perfusion
▶
Capillary refill delay
Cool extremities
Mottling
GU and pelvic focused exam
GU exam as indicated
▶
Costovertebral angle tenderness
Testicular position and tenderness
Scrotal swelling
Pelvic exam as indicated
▶
Cervical motion tenderness
Adnexal tenderness
Discharge
Lab Studies
Core labs for undifferentiated abdominal pain
Baseline evaluation set
▶
CBC with differential
▶
Leukocytosis pattern
Anemia pattern
Electrolytes and renal function
▶
Sodium
Potassium
Creatinine
Liver enzymes and bilirubin
▶
AST
ALT
ALP
Total bilirubin
Lipase
▶
Pancreatitis support
Normal lipase does not fully exclude early pancreatitis
Urinalysis
▶
Hematuria support for stone
Pyuria support for infection
Pregnancy test for pregnancy potential
▶
Urine test
Serum test when high stakes
Sepsis and ischemia evaluation
High risk adjuncts
▶
Lactate
▶
Elevated suggests shock or ischemia
Normal does not exclude mesenteric ischemia
Venous blood gas
▶
Acidemia assessment
Hypercapnia assessment
Blood cultures when antibiotics planned
▶
Two sets from separate sites
Timing before antibiotics local protocol dependent
Bleeding and procedure readiness
Hemorrhage risk labs
▶
Type and screen
▶
Transfusion readiness
Crossmatch if active bleeding
Coagulation testing
▶
INR
aPTT
Pitfalls and timing limitations
Common limitations
▶
Early appendicitis with normal WBC
Early cholecystitis with normal labs
Early ischemia with normal lactate
Imaging
Scoring Systems
Decision tools for imaging and risk
▶
Alvarado score for appendicitis
▶
Lower risk supports observation with reassessment
Higher risk supports imaging or surgical consultation
AIR score for appendicitis
▶
Intermediate risk supports imaging
High risk supports surgical pathway
BISAP score for pancreatitis
▶
Higher score correlates with severe course
Use for disposition and monitoring intensity
Glasgow Blatchford score for upper GI bleeding
▶
Low risk supports outpatient management
Higher risk supports admission and urgent endoscopy planning
MRI
MRI indications
▶
Pregnancy with concern for appendicitis
Pelvic pathology when ultrasound nondiagnostic
MRI cautions
▶
Implanted ferromagnetic devices
Severe claustrophobia
MRI interpretation pearls
▶
Appendiceal diameter and periappendiceal inflammation
Ovarian torsion supportive signs
CT
CT abdomen pelvis with IV contrast
▶
Undifferentiated abdominal pain with alarm features
Suspected appendicitis when ultrasound nondiagnostic
Suspected diverticulitis with complicated features
CT angiography abdomen pelvis
▶
Suspected mesenteric ischemia
Pain out of proportion to exam
Elevated lactate with abdominal pain
CT precautions
▶
Contrast allergy history
Reduced kidney function
Pregnancy
CT interpretation pitfalls
▶
Early appendicitis false negatives
Early ischemia false negatives
Ultrasound
Right upper quadrant ultrasound
▶
Suspected gallstones
Suspected cholecystitis
Pelvic ultrasound with Doppler
▶
Suspected ovarian torsion
Suspected ectopic pregnancy
Renal ultrasound
▶
Hydronephrosis assessment
Pregnancy or radiation avoidance
POCUS protocols
▶
FAST when trauma or shock unclear
Abdominal aorta screening in shock
Ultrasound pitfalls
▶
Nondiagnostic appendix common
Torsion can have preserved flow early
Special Tests
Bedside and procedural diagnostics
Bedside tests
▶
Rectal exam when bleeding concern
Stool guaiac limitations
Paracentesis when ascites
▶
Spontaneous bacterial peritonitis evaluation
PMN count threshold 250 per microliter
Nasogastric decompression trial
▶
Severe vomiting with obstruction concern
Symptom response does not exclude strangulation
Specialty pathway tests
Endoscopy pathway triggers
▶
Suspected upper GI bleed
Refractory pain with alarm features
Gynecology pathway triggers
▶
Suspected ectopic pregnancy
Suspected ovarian torsion
ECG
Indications and high risk patterns
When abdominal pain warrants ECG
▶
Epigastric pain
Older adult
Diabetes mellitus
Significant risk factors for coronary disease
High risk ECG findings
▶
ST elevation
New ST depression
New T wave inversion in contiguous leads
New left bundle branch block
Serial ECG logic
▶
Ongoing ischemic symptoms repeat within 15 to 30 minutes
Initial nondiagnostic with high suspicion repeat with troponin pathway
Assessment
Problem representation and severity
Working problem statement
▶
Location pattern
Associated symptoms pattern
Hemodynamic stability
Severity stratification
▶
Stable without alarm features
Stable with alarm features
Unstable or shock
Key complications to rule out
Immediate threats list
▶
Peritonitis
Ischemia
Hemorrhage
Sepsis
Pregnancy related emergency
Diagnostic uncertainty and alternatives
Competing diagnoses
▶
Mimics list
Reassessment dependent evolution
Short interval follow up need
Plan
First 5 minutes critical patient
Immediate stabilization workflow
▶
Continuous monitoring
▶
Cardiac monitor
Pulse oximetry
IV access
▶
Two large bore peripheral IV when shock or bleeding concern
Intraosseous access if IV access delayed
Oxygen and ventilation
▶
Oxygen if saturation less than 92 percent
Escalate airway support if declining mental status
Point of care glucose
▶
Treat hypoglycemia per protocol
Consider DKA if hyperglycemia with acidosis
Analgesia and antiemetics
Symptom control regimen
▶
Acetaminophen PO or IV 1000 mg
▶
Maximum 3000 mg per day older adult or liver disease risk
Avoid in severe acute liver failure
Ketorolac IV 15 mg
▶
Avoid in pregnancy beyond 20 weeks local protocol dependent
Avoid in chronic kidney disease
Morphine IV 0.05 mg per kg
▶
Repeat every 10 to 15 minutes to effect
Avoid or reduce in severe hypotension
Hydromorphone IV 0.5 mg
▶
Repeat every 10 to 15 minutes to effect
Higher risk respiratory depression with co sedatives
Ondansetron IV 4 mg
▶
QT prolongation risk
Use caution with hypokalemia
Metoclopramide IV 10 mg
▶
Akathisia risk
Avoid in bowel obstruction suspicion
Fluids and antibiotics when indicated
Hemodynamic support
▶
Isotonic crystalloid bolus 500 mL
▶
Reassess after each bolus
Smaller boluses for heart failure
Septic shock fluid target local protocol dependent
▶
Consider 30 mL per kg within 3 hours
Early vasopressor if persistent hypotension
Empiric antibiotics triggers
▶
Suspected intra abdominal sepsis with hypotension
Peritonitis or perforation concern
Cholangitis concern
Diagnostic sequencing
Test prioritization
▶
Pregnancy test before ionizing imaging when pregnancy potential
ECG and troponin pathway for epigastric pain with risk factors
Lactate and CTA for suspected ischemia
Reassessment loop
Time based reassessment
▶
Recheck vitals within 15 to 30 minutes after analgesia or fluids
Repeat abdominal exam after symptom control
Escalate imaging or consult if worsening tenderness or new peritoneal signs
Disposition
Level of care criteria
ICU criteria
▶
Persistent hypotension after fluids
Lactate persistently elevated with shock
Need for vasopressors
Respiratory failure risk
Inpatient admission criteria
▶
Peritonitis or suspected perforation
Complicated appendicitis concern
Complicated diverticulitis concern
Pancreatitis with persistent pain or vomiting
Uncontrolled pain requiring parenteral opioids
Observation pathway criteria
▶
Undifferentiated pain without alarm features
Indeterminate imaging with stable exam
Serial exams and labs planned
Discharge criteria
▶
Hemodynamically stable
Pain controlled with oral regimen
Tolerating oral fluids
No peritonitis on repeat exam
Reliable follow up and return ability
Follow up timing
Copy
Outpatient follow up windows
▶
Primary care within 24 to 72 hours if undifferentiated
Specialty referral timing based on suspected diagnosis
Discharge Instructions
Copy discharge instructions
Copy
Patient discharge text
▶
Your evaluation today did not show a life threatening cause for your abdominal pain at this time
Return immediately for worsening pain
Return immediately for fainting or severe weakness
Return immediately for fever
Return immediately for vomiting that prevents fluids
Return immediately for blood in vomit or stool
Return immediately for new chest pain or trouble breathing
Pain control plan
▶
Acetaminophen as directed on the label
Avoid NSAIDs if kidney disease or blood thinners
Hydration plan
▶
Small frequent sips
Oral rehydration solution if diarrhea
Follow up plan
▶
Follow up with your clinician within 1 to 3 days
Earlier follow up if symptoms worsen
References
Core guidelines and decision tools
Source list
▶
American College of Radiology Appropriateness Criteria acute nonlocalized abdominal pain 2023
World Society of Emergency Surgery guidelines for acute appendicitis 2020
Tokyo Guidelines for acute cholecystitis and cholangitis 2018
American College of Gastroenterology guideline for acute pancreatitis 2013
Surviving Sepsis Campaign international guidelines 2021
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Clinical Approaches
Abdominal Pain, Undifferentiated