01 History /hx 62
› Core history elements
› Chief concern
› Symptom onset context
› Pattern and trajectory
› Baseline status
› Prior episodes
› OPQRST framework
› Onset
› Sudden
› Gradual
› Provocation and palliation
› Worse with inspiration
› Worse with movement
› Worse after meals
› Relief with antacids
› Relief with leaning forward
› Quality
› Sharp
› Dull
› Burning
› Tearing
› Region and radiation
› Left upper quadrant
› Left shoulder
› Back
› Chest
› Severity
› Mild
› Moderate
› Severe
› Timing
› Constant
› Intermittent
› Postprandial
› Exertional
› Symptom associations
› Fever
› Nausea
› Vomiting
› Hematemesis
› Melena
› Diarrhea
› Constipation
› Chest pain
› Dyspnea
› Cough
› Pleuritic pain
› Syncope
› Dysuria
› Flank pain
› Trigger review
› Blunt abdominal trauma
› Recent vomiting or retching
› Recent endoscopy
› Heavy lifting
› Recent infection
› Recent travel
› Population modifiers
› Pregnancy status
› Older adult frailty
› Immunocompromised status
› Anticoagulant use
Show 36 more ▾ 02 Alarm Features /alarm 27
› Resuscitation triggers
› Hypotension
› Shock index greater than 1
› Altered mental status
› Respiratory distress
› Ongoing hematemesis
› Large volume melena
High risk historical features
› Time critical history signals
› Sudden severe pain at onset
› Syncope with pain
› Recent significant trauma
› Known aneurysm
› Anticoagulation with new pain
› Recent MI or stent
› Exam danger findings
› Peritonitis
› Rigid abdomen
› Rebound tenderness
› Focal neurologic deficit
› New murmur
› Unequal pulses
Vital sign danger thresholds
› Physiologic danger patterns
› Systolic BP less than 90 mmHg
› Heart rate greater than 120 per minute
› Respiratory rate greater than 24 per minute
› Oxygen saturation less than 92 percent on room air
› Temperature 38.5 C or higher
Show 3 more ▾ 03 Medications /meds 18
› Medication exposure
› Anticoagulants
› Antiplatelets
› NSAIDs
› Steroids
› GLP 1 receptor agonists
› Opioids
› Recent antibiotics
› Non prescription exposures
› Bismuth
› Antacids
› Iron supplements
› Herbal supplements
Therapy contraindications
› Key contraindication checks
› NSAID avoidance in suspected GI bleed
› QT prolonging drug combinations
› Contrast precautions
› Metformin with acute kidney injury concern
06 Collateral History and Family History /chafh 9
Collateral and reliability
› Source and reliability
› Family or caregiver history
› EMS report
› Prior records availability
› Heritable and early disease
› Early coronary artery disease
› Aortic aneurysm or dissection
› Inherited hemolytic disorders
› Inflammatory bowel disease
08 Differential Diagnosis /ddx 67
› Cannot miss diagnoses
› Acute coronary syndrome (I21.9)
› Epigastric or LUQ discomfort equivalent
› Risk increased with exertional symptoms
› Aortic dissection (I71.00)
› Sudden severe pain
› Pulse deficit
› Neurologic symptoms
› Ruptured abdominal aortic aneurysm (I71.3)
› Hypotension
› Syncope
› Back or flank radiation
› Splenic rupture
› Trauma history
› Left shoulder pain
› Hypotension
› Upper GI bleed (K92.2)
› Hematemesis
› Melena
› NSAID exposure
› Perforated viscus (K63.1)
› Peritonitis
› Free air on imaging
› Pulmonary embolism (I26.99)
› Pleuritic pain
› Dyspnea
› Tension pneumothorax (J93.0)
› Sudden dyspnea
› Unilateral absent breath sounds
› High frequency etiologies
› Gastritis or peptic ulcer disease (K29.70)
› Postprandial pain
› NSAID exposure
› Acute pancreatitis (K85.9)
› Epigastric or LUQ pain
› Radiation to back
› Left lower lobe pneumonia (J18.9)
› Fever
› Cough
› Nephrolithiasis (N20.0)
› Flank radiation
› Hematuria
› Constipation
› Reduced bowel movements
› Distension
› Musculoskeletal pain
› Reproducible with palpation
› Worse with movement
› Lower probability considerations
› Splenic infarct
› Atrial fibrillation
› Hypercoagulable state
› Splenic abscess
› Prolonged fever
› Immunocompromised state
› Gastric volvulus
› Severe retching
› Inability to pass NG tube
› Herpes zoster
› Dermatomal pain
› Rash timing lag
› Mesenteric ischemia (K55.9)
› Pain out of proportion
› Elevated lactate
› Inflammatory bowel disease flare (K50.90)
› Diarrhea
› Weight loss
Show 40 more ▾ 09 Past Medical History /pmh 15
Relevant diagnoses and events
› Baseline conditions
› Coronary artery disease (I25.10)
› Heart failure (I50.9)
› Atrial fibrillation (I48.91)
› Chronic kidney disease (N18.9)
› Chronic liver disease
Prior procedures and devices
› Procedure history
› Prior abdominal surgery
› Prior endoscopy
› Coronary stent
› Pacemaker or ICD
› Episode pattern
› Prior pancreatitis
› Prior peptic ulcer disease
› Prior kidney stones
11 Lab Studies /labs 25
› Initial lab set
› CBC
› Electrolytes
› Creatinine
› Glucose
› Liver enzymes
› Bilirubin
› Lipase
› Venous blood gas if ill
Hemorrhage and coagulation
› Bleeding evaluation
› INR
› PTT
› Type and screen
› Type and crossmatch if unstable
› Cardiac risk labs
› Troponin with serial strategy
› BNP when heart failure concern
Infection and ischemia clues
› Adjunct tests
› Lactate
› Blood cultures when febrile and septic concern
› Urinalysis
› Pregnancy test when applicable
› Common pitfalls
› Normal early lipase in very early pancreatitis
› Lactate may be normal early in mesenteric ischemia
Show 2 more ▾ 12 Imaging /img 17
› When scores influence imaging choice
› PERC for PE exclusion
› Wells score for PE pretest probability
› HEART score for chest pain risk
› MRI considerations
› Alternative when CT contraindicated
› Limited role in acute unstable abdominal pain
› MRCP when biliary obstruction concern and stable
› CT pathways
› CT angiography chest abdomen pelvis for dissection concern
› CT abdomen pelvis with IV contrast for perforation or ischemia concern
› CT abdomen pelvis without contrast for renal colic when stable
› Ultrasound use cases
› POCUS FAST when trauma or hemorrhage concern
› POCUS abdominal aorta screening when hypotension and rupture concern
› Left pleural effusion assessment
› Splenic size and free fluid support findings
13 Special Tests /spec 7
› Bedside diagnostics
› Rectal exam when GI bleed concern
› Nasogastric aspirate local protocol dependent
› Point of care hemoglobin local protocol dependent
Respiratory focused tests
› Pulmonary adjuncts
› Peak flow when asthma mimic suspected
› D dimer only in low to intermediate PE risk
14 ECG /ecg 13
› ECG triggers
› Any upper abdominal pain with cardiac risk
› Diaphoresis
› Dyspnea
› Syncope
› ECG danger findings
› STEMI criteria
› New ischemic ST depression
› New T wave inversion in contiguous leads
› Ventricular arrhythmia
› Repetition logic
› Repeat in 15 to 30 minutes if ongoing concern
› Repeat with new symptoms or hemodynamic change
15 Assessment /ax 13
› Working synthesis
› Hemodynamic status category
› Peritonitis present or absent
› Cardiac and vascular risk context
› High risk flags
› Shock physiology
› Active bleeding features
› Suspected vascular catastrophe
› Complication screen
› Pancreatitis complications
› Perforation
› Sepsis
› ACS equivalent
16 Plan /plan 33
› Immediate stabilization
› Cardiac monitor
› Pulse oximetry
› Two large bore IVs if unstable
› Oxygen if saturation less than 92 percent
› Massive transfusion activation local protocol dependent
› ! Splenic laceration → › ! Acute pancreatitis → › Test prioritization
› ECG within 10 minutes when cardiac concern
› Bedside ultrasound in unstable patient
› CTA when dissection concern and stable enough
Analgesia and antiemetics
› Symptom control options
› Acetaminophen PO 1000 mg once
› Hydromorphone IV 0.5 mg
› Titrate every 10 minutes as needed
› Ondansetron IV 4 mg
› Avoid NSAIDs in suspected GI bleed or renal injury
Condition directed therapy
› Targeted treatments
› Suspected GI bleed
› Pantoprazole IV 80 mg bolus
› Then 8 mg per hour infusion local protocol dependent
› Suspected pancreatitis
› Balanced crystalloid bolus 10 mL per kg if hypovolemic
› Avoid routine antibiotics unless infected necrosis concern
› Suspected ACS
› Aspirin PO 160 mg chewable if no contraindication
› Nitrates contraindicated with hypotension or RV infarct concern
› Recheck cadence
› Pain score after each intervention
› Vitals every 15 minutes if unstable
› Abdominal exam repeat after analgesia
› Escalate level of care for deterioration
Show 10 more ▾ 17 Disposition /dispo 19
› Higher acuity criteria
› Ongoing hypotension after fluids
› Vasopressor requirement
› Active GI bleeding with transfusion need
› Suspected dissection
› Admission indications
› Pancreatitis with organ dysfunction
› Pneumonia with hypoxia
› Splenic injury
› Uncontrolled pain or vomiting
› Observation candidates
› Low risk chest pain pathway eligible
› Stable renal colic with pain control
› Safe discharge requirements
› Stable vitals
› Pain controlled with oral meds
› Oral intake tolerated
› No peritonitis
› Reliable follow up
18 Discharge Instructions /di 23
Copy discharge instructions
Copy › Diagnosis summary
› Left upper abdominal pain evaluation today did not show an emergency cause on the tests performed
› Some conditions can evolve over time and may not show early on initial testing
› Medications
› Use acetaminophen as directed on the label
› Avoid NSAIDs if you have stomach bleeding risk or kidney problems
› Take prescribed nausea medicine only as directed
› Activity
› Avoid heavy lifting until symptoms improve
› Hydration with frequent small sips
› Follow up
› Primary care or clinic follow up within 24 to 72 hours
› Return sooner if symptoms worsen
› Return to ED now for
› Fainting
› Chest pain
› Trouble breathing
› Vomiting blood
› Black stools
› Fever with worsening pain
› New severe sudden pain
› Weakness on one side
› Inability to keep fluids down