Abdominal Pain, UndifferentiatedAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

598 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Abdominal Distension Abdominal Pain, Undifferentiated Acute Abdominal Pain (general)Suspected Incarcerated Or Strangulated Hernia Pancreatitis Concern Biliary Colic And Cholecystitis Concern Appendicitis Concern Diverticulitis Concern Rectal Pain And Anorectal Complaints Dysphagia And Food Bolus Impaction Foreign Body Ingestion Refractory Vomiting And Recurrent Vomiting Syndromes Cannabis Associated Hyperemesis Upper Gastrointestinal Bleeding Symptoms (melena)Lower Gastrointestinal Bleeding And Hematochezia Constipation And Obstipation Diarrhea Acute Hepatitis And Jaundice Concern Right Upper Quadrant Pain Epigastric Pain Left Upper Quadrant Pain Right Lower Quadrant Pain Left Lower Quadrant Pain Suprapubic Pain

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx81

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

02Alarm Features/alarm31

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

03Medications/meds18

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

04Diet/diet16

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

05Review of Systems/ros19

›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

06Collateral History and Family History/chafh14

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

07Risk Factors/rf22

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

08Differential Diagnosis/ddx104

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

09Past Medical History/pmh15

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

10Physical Exam/exam39

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

11Lab Studies/labs43

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

12Imaging/img52

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 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

13Special Tests/spec15

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

14ECG/ecg13

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

15Assessment/ax18

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

16Plan/plan51

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

17Disposition/dispo24

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

›Outpatient follow up windows

›Primary care within 24 to 72 hours if undifferentiated

›Specialty referral timing based on suspected diagnosis

18Discharge Instructions/di17

Copy discharge instructions

›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

19References/r6

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Abdominal Pain, UndifferentiatedAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

598 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx81

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

02Alarm Features/alarm31

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

03Medications/meds18

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

04Diet/diet16

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

05Review of Systems/ros19

›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

06Collateral History and Family History/chafh14

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

07Risk Factors/rf22

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

08Differential Diagnosis/ddx104

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

09Past Medical History/pmh15

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

10Physical Exam/exam39

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

11Lab Studies/labs43

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

12Imaging/img52

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 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

13Special Tests/spec15

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

14ECG/ecg13

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

15Assessment/ax18

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

16Plan/plan51

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

17Disposition/dispo24

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

›Outpatient follow up windows

›Primary care within 24 to 72 hours if undifferentiated

›Specialty referral timing based on suspected diagnosis

18Discharge Instructions/di17

Copy discharge instructions

›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

19References/r6

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.