Pediatric Abdominal PainAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

577 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▾

Fever In The Neonate And Young Infant Pediatric Fever By Age 0 To 28 Days Pediatric Fever By Age 29 To 60 Days Pediatric Fever By Age 2 To 24 Months Pediatric Respiratory Distress Croup And Stridor In Children Pediatric Dehydration Pediatric Abdominal Pain Febrile Seizure Rash In The Child Poor Feeding And Lethargy In The Infant Vomiting In The Child Diarrhea In The Child Pediatric Trauma Evaluation Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern Lethargy And Altered Mental Status In The Child

Environmental and Exposure4▾

01History/hx82

HPI

›Abdominal pain context

›Age group

›Caregiver reliability

›Pain onset context

›Symptom trajectory

›Prior episodes

›Baseline bowel pattern

›Baseline appetite and growth

Onset

›Onset

›Sudden

›Gradual

›Time since onset

›Triggering event

Provocation/Palliation

›Provocation and palliation

›Worse with movement

›Worse with eating

›Worse with urination

›Worse with defecation

›Relief with stool

›Relief with vomiting

Quality

›Quality

›Crampy

›Colicky

›Sharp

›Burning

›Constant

Region/Radiation

›Region and radiation

›Periumbilical

›Right lower quadrant

›Right upper quadrant

›Epigastric

›Suprapubic

›Flank

›Radiation to back

›Radiation to groin

Severity

›Severity

›Current pain score

›Peak pain score

›Functional impact

›Sleep disruption

Timing

›Timing

›Intermittent

›Constant

›Episodes duration

›Progressive worsening

›Nocturnal wakening

Associated symptoms

›Associated symptoms

›Fever

›Nausea

›Vomiting

›Bilious vomiting

›Hematemesis

›Diarrhea

›Bloody stool

›Constipation

›Dysuria

›Hematuria

›Frequency

›Vaginal bleeding

›Vaginal discharge

›Testicular pain

›Cough or sore throat

›Rash

›Weight loss

Intake and output

›Intake and output

›Oral intake

›Urine output

›Last wet diaper

›Stool frequency

›Last stool

Gynecologic and sexual health

›Gynecologic and sexual health

›Menarche status

›LMP

›Pregnancy possibility

›Sexual activity

›Contraception

›STI risk

Surgical and ingestion history

›Surgical and ingestion history

›Prior abdominal surgery

›Foreign body ingestion

›Toxin exposure

›Caustic exposure

02Alarm Features/alarm29

Immediate life threats

›Immediate life threats

›Shock

›Peritonitis

›Suspected volvulus

›Testicular torsion

›Ectopic pregnancy

Vital sign danger thresholds

›Vital sign danger thresholds

›Hypotension for age

›Persistent tachycardia

›SpO2 low

›Fever with toxicity

High risk vomiting and stool patterns

›High risk vomiting and stool patterns

›Bilious vomiting

›Projectile vomiting in infant

›Hematemesis

›Bloody stool

›Currant jelly stool

High risk exam findings

›High risk exam findings

›Rebound tenderness

›Guarding

›Rigidity

›Involuntary guarding

›Absent bowel sounds with toxicity

›Distended tense abdomen

Escalation triggers

›Escalation triggers

›If shock features then resuscitation bay

›If bilious vomiting then emergent surgical evaluation

›If peritonitis then NPO and urgent surgery consult

›If suspected torsion then immediate urology consult and no delay for imaging

03Medications/meds34

Current and recent meds

›Current and recent meds

›Antibiotics in last 30 days

›NSAIDs

›Acetaminophen

›Opioids

›Steroids

›Laxatives

›Antidiarrheals

High risk exposures

›High risk exposures

›Iron

›Salicylates

›Acetaminophen overdose risk

›Cannabis

›Energy drinks

ED symptom control dosing

›ED symptom control dosing

›Acetaminophen

›15 mg/kg PO

›Max 1000 mg per dose

›Max 60 mg/kg/day

›Ibuprofen

›10 mg/kg PO

›Max 600 mg per dose

›Avoid if dehydration or renal risk

›Ondansetron

›0.15 mg/kg PO or ODT

›Max 8 mg per dose

›Morphine

›0.05 mg/kg IV

›Repeat every 10 to 20 minutes as needed

Contraindications and interactions

›Contraindications and interactions

›NSAIDs with GI bleed risk

›NSAIDs with renal impairment risk

›Opioids with respiratory depression risk

›QT prolonging combinations with ondansetron

04Diet/diet17

Recent intake patterns

›Recent intake patterns

›Poor intake duration

›Oral fluid tolerance

›Food triggers

Hydration indicators

›Hydration indicators

›Thirst

›Dry mouth

›Tears reduced

›Decreased urine

Foodborne risk

›Foodborne risk

›Undercooked meats

›Unpasteurized dairy

›Recent restaurant outbreak exposure

Lactose and fermentable triggers

›Lactose and fermentable triggers

›Dairy trigger pattern

›High sorbitol intake

›High fructose intake

05Review of Systems/ros36

Constitutional

›Constitutional

›Fever

›Fatigue

›Weight loss

›Night sweats

Gastrointestinal

›Gastrointestinal

›Vomiting

›Bilious vomiting

›Diarrhea

›Constipation

›Blood in stool

›Melena

›Jaundice

Genitourinary

›Genitourinary

›Dysuria

›Hematuria

›Frequency

›Flank pain

›Vaginal bleeding

›Vaginal discharge

›Testicular pain

Respiratory and ENT

›Respiratory and ENT

›Cough

›Sore throat

›Otalgia

›Dyspnea

Skin and musculoskeletal

›Skin and musculoskeletal

›Rash

›Joint pain

›Limp

›Back pain

Neurologic and endocrine

›Neurologic and endocrine

›Headache

›Altered mental status

›Polyuria

›Polydipsia

06Collateral History and Family History/chafh19

Collateral source

›Collateral source

›Parent

›Guardian

›School

›EMS

Family history GI and surgical

›Family history GI and surgical

›Inflammatory bowel disease

›Celiac disease

›Appendicitis in siblings

›Gallstones

Family history renal and metabolic

›Family history renal and metabolic

›Nephrolithiasis

›Type 1 diabetes mellitus

›Sickle cell disease (D57.1)

Household exposures

›Household exposures

›Sick contacts

›Daycare outbreak

›Pets and reptiles

›Travel exposures

07Risk Factors/rf25

Age specific risks

›Age specific risks

›Infant volvulus risk

›Toddler intussusception risk

›Adolescent pregnancy risk

›Adolescent STI risk

Infection and inflammation risks

›Infection and inflammation risks

›Recent gastroenteritis

›Recent URI

›Recent antibiotics

›Immunocompromise

Surgical abdomen risks

›Surgical abdomen risks

›Prior abdominal surgery

›Hernia history

›Known malrotation

›Known gallstones

Renal stone and UTI risks

›Renal stone and UTI risks

›Prior UTI

›Vesicoureteral reflux history

›Poor hydration

›High salt intake

Medication and toxin risks

›Medication and toxin risks

›NSAID use

›Iron access

›Cannabis use

›Caustic exposure

08Differential Diagnosis/ddx73

Life threatening

›Life threatening

›Malrotation with volvulus (K56.2)

›Bilious vomiting

›Rapid deterioration

›Appendicitis with perforation (K35.32)

›Migration to RLQ

›Peritonitis

›Intussusception (K56.1)

›Colicky pain episodes

›Bloody stool

›Ovarian torsion (N83.5)

›Sudden unilateral lower abdominal pain

›Vomiting

›Testicular torsion (N44)

›Scrotal pain

›High riding testis

›Ectopic pregnancy (O00.9)

›Positive pregnancy test

›Syncope or hypotension

›Diabetic ketoacidosis (E10.10)

›Abdominal pain with vomiting

›Kussmaul breathing

›Sepsis (A41.9)

›Toxic appearance

›Hypotension

Common

›Common

›Viral gastroenteritis (A08.4)

›Vomiting and diarrhea

›Sick contacts

›Constipation (K59.00)

›Infrequent stools

›Stool burden

›Mesenteric adenitis (I88.0)

›URI symptoms

›RLQ tenderness mimic

›UTI (N39.0)

›Dysuria

›Suprapubic pain

›Functional abdominal pain (R10.84)

›Normal growth

›No alarm features

›Gastritis or GERD (K29.70)

›Epigastric burning

›Relation to meals

Less common

›Less common

›Pancreatitis (K85.90)

›Epigastric pain

›Pain to back

›Cholecystitis (K81.0)

›RUQ pain

›Murphy sign

›Nephrolithiasis (N20.0)

›Colicky flank pain

›Hematuria

›Pneumonia with referred pain (J18.9)

›Cough

›Tachypnea

›Henoch Schonlein purpura (D69.0)

›Palpable purpura

›Arthralgia

›Inflammatory bowel disease (K50.90)

›Weight loss

›Bloody diarrhea

Mimics and pitfalls

›Mimics and pitfalls

›Abdominal wall pain

›Pain with tensing muscles

›Localized tenderness

›Anxiety related symptoms

›Hyperventilation

›Normal exam trend

›Early appendicitis

›Initially periumbilical pain

›Normal early labs

09Past Medical History/pmh17

Chronic conditions

›Chronic conditions

›Asthma (J45.909)

›Diabetes mellitus type 1 (E10.9)

›Sickle cell disease (D57.1)

›Inflammatory bowel disease (K50.90)

Prior similar episodes

›Prior similar episodes

›Prior appendicitis evaluation

›Prior constipation episodes

›Prior UTIs

Surgeries and procedures

›Surgeries and procedures

›Appendectomy

›Hernia repair

›Abdominal surgery history

Baseline function

›Baseline function

›Normal activity level

›Baseline diet

›Growth trajectory

10Physical Exam/exam41

General and vital signs

›General and vital signs

›Toxic appearance

›Hydration status

›Perfusion

›Mental status

Abdomen inspection and auscultation

›Abdomen inspection and auscultation

›Distension

›Visible peristalsis

›Surgical scars

›Bowel sounds

Abdomen palpation and percussion

›Abdomen palpation and percussion

›Focal tenderness location

›Guarding

›Rebound

›Rigidity

›Hepatosplenomegaly

›Mass

Peritoneal and appendicitis maneuvers

›Peritoneal and appendicitis maneuvers

›Pain with cough or hop

›Rovsing sign

›Psoas sign

›Obturator sign

Hernia and genitourinary

›Hernia and genitourinary

›Inguinal hernia exam

›Costovertebral angle tenderness

›Suprapubic tenderness

Testicular and pelvic considerations

›Testicular and pelvic considerations

›Cremasteric reflex

›Testis lie and tenderness

›Scrotal edema or erythema

›External genital exam findings

Skin and joints

›Skin and joints

›Purpura

›Urticaria

›Joint swelling

›Limp

Cardiopulmonary

›Cardiopulmonary

›Tachypnea

›Focal crackles

›Chest wall tenderness

›Murmur

11Lab Studies/labs27

Core ED labs by risk profile

›Core ED labs by risk profile

›CBC for infection or anemia concern

›Electrolytes for dehydration or vomiting

›Glucose for DKA screen

›CRP for inflammatory process support

Urine testing

›Urine testing

›Urinalysis for UTI

›Urine culture if UA suggestive

›Hematuria for stone support

Pregnancy and STI testing

›Pregnancy and STI testing

›Urine beta hCG in post menarche

›NAAT for gonorrhea

›NAAT for chlamydia

Pancreatic and hepatobiliary labs

›Pancreatic and hepatobiliary labs

›Lipase for pancreatitis

›AST

›ALT

›Bilirubin

Severe illness labs

›Severe illness labs

›Venous blood gas for acidosis

›Lactate for hypoperfusion

›Blood culture if sepsis concern

Interpretation pitfalls

›Interpretation pitfalls

›Normal WBC does not exclude appendicitis

›Early appendicitis may have normal CRP

›Ketonuria may reflect starvation

›UTI and appendicitis can coexist

12Imaging/img30

Scoring Systems

›Appendicitis risk tools

›Pediatric Appendicitis Score

›Migration of pain

›Anorexia

›Nausea or vomiting

›Fever

›RLQ tenderness

›Cough percussion hopping tenderness

›Leukocytosis

›Neutrophilia

›pARC

›Use with clinical exam and labs

›Local protocol dependent thresholds

MRI

›MRI abdomen and pelvis

›Appendicitis evaluation when ultrasound nondiagnostic

›Pregnancy or radiation avoidance priority

›Limited availability and motion sensitivity

›CT abdomen and pelvis

›Reserved for equivocal cases after ultrasound

›Contrast considerations

›Allergy history

›Renal risk

›Radiation risk higher in children

Ultrasound

›Ultrasound first line

›RLQ ultrasound for appendicitis

›Pelvic ultrasound for ovarian pathology

›Pyloric ultrasound for infant vomiting pattern

›Intussusception ultrasound for colicky pain

›False negatives with early appendicitis

›Nondiagnostic appendix common

13Special Tests/spec11

Bedside maneuvers

›Bedside maneuvers

›Carnett test for abdominal wall pain

›Jump or hop test for peritoneal irritation

›Rectal exam selective

POCUS

›POCUS

›Hydration assessment

›Bladder volume

›Free fluid screening

Procedural diagnostics

›Procedural diagnostics

›Enema reduction pathway for intussusception

›Surgical exploration pathway if volvulus suspected

14ECG/ecg11

When ECG matters in abdominal pain

›When ECG matters in abdominal pain

›Epigastric pain with risk factors

›Syncope or presyncope

›Hyperkalemia concern

High risk patterns

›High risk patterns

›ST elevation

›Wide QRS

›QT prolongation

Serial ECG logic

›Serial ECG logic

›Persistent concerning symptoms

›Evolving vitals or exam

15Assessment/ax25

Problem representation

›Problem representation

›Age

›Pain location

›Time course

›Associated symptoms

Severity and acuity

›Severity and acuity

›Hemodynamic stability

›Toxic appearance

›Hydration severity

Risk stratification

›Risk stratification

›Appendicitis score category

›Need for serial exams

›Need for surgical consult now

Working diagnoses

›Working diagnoses

›Gastroenteritis (A08.4)

›Constipation (K59.00)

›Appendicitis rule out (K35.80)

›UTI (N39.0)

Complications to exclude

›Complications to exclude

›Perforation

›Sepsis

›Dehydration with electrolyte derangement

Diagnostic uncertainty

›Diagnostic uncertainty

›Alternative diagnoses listed

›Plan for reassessment timing

16Plan/plan33

First 5 minutes

›First 5 minutes

›Airway and breathing risk

›Continuous monitoring if unstable

›IV access criteria

›If shock features then two IVs

›If difficult access then IO

›Point of care glucose if altered or vomiting

›NPO if surgical abdomen possible

Analgesia and antiemetics

›Analgesia and antiemetics

›Acetaminophen dosing per weight

›Ibuprofen dosing per weight

›Opioid for severe pain with monitoring

›Ondansetron dosing per weight

Fluids and electrolytes

›Fluids and electrolytes

›Isotonic bolus

›20 mL/kg IV

›Repeat based on perfusion

›Maintenance fluids if ongoing losses

›Electrolyte correction if abnormal

Diagnostic sequencing

›Diagnostic sequencing

›Pregnancy test early in post menarche

›UA early if urinary symptoms

›Ultrasound first line for RLQ or pelvic pain

›CT or MRI if ultrasound nondiagnostic and high suspicion

Consultations

›Consultations

›Surgery for suspected appendicitis or obstruction

›Urology for suspected torsion

›Gynecology for suspected ovarian torsion or ectopic pregnancy

Reassessment loop

›Reassessment loop

›Repeat vitals every 30 to 60 minutes if concerning

›Repeat abdominal exam after analgesia

›Track urine output

›Escalate if worsening tenderness or new guarding

17Disposition/dispo23

ICU criteria

›ICU criteria

›Shock requiring ongoing boluses

›Vasopressor requirement

›Severe DKA

Inpatient admission criteria

›Inpatient admission criteria

›Surgical diagnosis

›Persistent vomiting with dehydration

›Intractable pain

›Unsafe home observation

Observation pathway criteria

›Observation pathway criteria

›Equivocal appendicitis with stable vitals

›Serial exams planned

›Repeat imaging planned

Discharge criteria

›Discharge criteria

›Stable vitals

›Pain controlled with oral meds

›Tolerating oral fluids

›No peritoneal signs

›Reliable follow up

Follow up timing

›Follow up timing

›Primary care within 24 to 72 hours

›Earlier if symptoms persist

›Specialty follow up if indicated

18Discharge Instructions/di29

Copy discharge instructions

›Summary

›Today you were evaluated for belly pain

›Your exam and tests did not show an emergency right now

›Medicines

›Use acetaminophen for pain as directed

›Use ibuprofen only if drinking well

›Use ondansetron only as prescribed

›Eating and drinking

›Small frequent sips of fluids

›Return to regular diet as tolerated

›Activity

›Rest today

›Normal activity as tolerated

›Follow up

›See your clinician in 1 to 3 days

›Return sooner if symptoms worsen

›Return now for

›Trouble breathing

›Fainting

›Severe or worsening pain

›New pain in the right lower belly

›Green vomit

›Blood in vomit

›Blood in stool

›Fever with worsening pain

›Hard swollen belly

›Testicle pain

›Vaginal bleeding with pain

›Not peeing much

19References/r15

Guidelines and decision tools

›American College of Radiology

›ACR Appropriateness Criteria for suspected appendicitis in children

›Imaging first line ultrasound emphasis

›American Pediatric Surgical Association

›Appendicitis management guidance

›Nonoperative pathways local protocol dependent

›Pediatric Appendicitis Risk Calculator

›Risk stratification tool for suspected appendicitis

›Use with clinical judgment

›NASPGHAN

›Functional abdominal pain disorders guidance

›Alarm feature based evaluation

›Infectious Diseases Society guidance

›Pediatric UTI diagnostic and treatment principles

›Local antibiogram dependent

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.

Pediatric Abdominal PainAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

577 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/hx82

HPI

›Abdominal pain context

›Age group

›Caregiver reliability

›Pain onset context

›Symptom trajectory

›Prior episodes

›Baseline bowel pattern

›Baseline appetite and growth

Onset

›Onset

›Sudden

›Gradual

›Time since onset

›Triggering event

Provocation/Palliation

›Provocation and palliation

›Worse with movement

›Worse with eating

›Worse with urination

›Worse with defecation

›Relief with stool

›Relief with vomiting

Quality

›Quality

›Crampy

›Colicky

›Sharp

›Burning

›Constant

Region/Radiation

›Region and radiation

›Periumbilical

›Right lower quadrant

›Right upper quadrant

›Epigastric

›Suprapubic

›Flank

›Radiation to back

›Radiation to groin

Severity

›Severity

›Current pain score

›Peak pain score

›Functional impact

›Sleep disruption

Timing

›Timing

›Intermittent

›Constant

›Episodes duration

›Progressive worsening

›Nocturnal wakening

Associated symptoms

›Associated symptoms

›Fever

›Nausea

›Vomiting

›Bilious vomiting

›Hematemesis

›Diarrhea

›Bloody stool

›Constipation

›Dysuria

›Hematuria

›Frequency

›Vaginal bleeding

›Vaginal discharge

›Testicular pain

›Cough or sore throat

›Rash

›Weight loss

Intake and output

›Intake and output

›Oral intake

›Urine output

›Last wet diaper

›Stool frequency

›Last stool

Gynecologic and sexual health

›Gynecologic and sexual health

›Menarche status

›LMP

›Pregnancy possibility

›Sexual activity

›Contraception

›STI risk

Surgical and ingestion history

›Surgical and ingestion history

›Prior abdominal surgery

›Foreign body ingestion

›Toxin exposure

›Caustic exposure

02Alarm Features/alarm29

Immediate life threats

›Immediate life threats

›Shock

›Peritonitis

›Suspected volvulus

›Testicular torsion

›Ectopic pregnancy

Vital sign danger thresholds

›Vital sign danger thresholds

›Hypotension for age

›Persistent tachycardia

›SpO2 low

›Fever with toxicity

High risk vomiting and stool patterns

›High risk vomiting and stool patterns

›Bilious vomiting

›Projectile vomiting in infant

›Hematemesis

›Bloody stool

›Currant jelly stool

High risk exam findings

›High risk exam findings

›Rebound tenderness

›Guarding

›Rigidity

›Involuntary guarding

›Absent bowel sounds with toxicity

›Distended tense abdomen

Escalation triggers

›Escalation triggers

›If shock features then resuscitation bay

›If bilious vomiting then emergent surgical evaluation

›If peritonitis then NPO and urgent surgery consult

›If suspected torsion then immediate urology consult and no delay for imaging

03Medications/meds34

Current and recent meds

›Current and recent meds

›Antibiotics in last 30 days

›NSAIDs

›Acetaminophen

›Opioids

›Steroids

›Laxatives

›Antidiarrheals

High risk exposures

›High risk exposures

›Iron

›Salicylates

›Acetaminophen overdose risk

›Cannabis

›Energy drinks

ED symptom control dosing

›ED symptom control dosing

›Acetaminophen

›15 mg/kg PO

›Max 1000 mg per dose

›Max 60 mg/kg/day

›Ibuprofen

›10 mg/kg PO

›Max 600 mg per dose

›Avoid if dehydration or renal risk

›Ondansetron

›0.15 mg/kg PO or ODT

›Max 8 mg per dose

›Morphine

›0.05 mg/kg IV

›Repeat every 10 to 20 minutes as needed

Contraindications and interactions

›Contraindications and interactions

›NSAIDs with GI bleed risk

›NSAIDs with renal impairment risk

›Opioids with respiratory depression risk

›QT prolonging combinations with ondansetron

04Diet/diet17

Recent intake patterns

›Recent intake patterns

›Poor intake duration

›Oral fluid tolerance

›Food triggers

Hydration indicators

›Hydration indicators

›Thirst

›Dry mouth

›Tears reduced

›Decreased urine

Foodborne risk

›Foodborne risk

›Undercooked meats

›Unpasteurized dairy

›Recent restaurant outbreak exposure

Lactose and fermentable triggers

›Lactose and fermentable triggers

›Dairy trigger pattern

›High sorbitol intake

›High fructose intake

05Review of Systems/ros36

Constitutional

›Constitutional

›Fever

›Fatigue

›Weight loss

›Night sweats

Gastrointestinal

›Gastrointestinal

›Vomiting

›Bilious vomiting

›Diarrhea

›Constipation

›Blood in stool

›Melena

›Jaundice

Genitourinary

›Genitourinary

›Dysuria

›Hematuria

›Frequency

›Flank pain

›Vaginal bleeding

›Vaginal discharge

›Testicular pain

Respiratory and ENT

›Respiratory and ENT

›Cough

›Sore throat

›Otalgia

›Dyspnea

Skin and musculoskeletal

›Skin and musculoskeletal

›Rash

›Joint pain

›Limp

›Back pain

Neurologic and endocrine

›Neurologic and endocrine

›Headache

›Altered mental status

›Polyuria

›Polydipsia

06Collateral History and Family History/chafh19

Collateral source

›Collateral source

›Parent

›Guardian

›School

›EMS

Family history GI and surgical

›Family history GI and surgical

›Inflammatory bowel disease

›Celiac disease

›Appendicitis in siblings

›Gallstones

Family history renal and metabolic

›Family history renal and metabolic

›Nephrolithiasis

›Type 1 diabetes mellitus

›Sickle cell disease (D57.1)

Household exposures

›Household exposures

›Sick contacts

›Daycare outbreak

›Pets and reptiles

›Travel exposures

07Risk Factors/rf25

Age specific risks

›Age specific risks

›Infant volvulus risk

›Toddler intussusception risk

›Adolescent pregnancy risk

›Adolescent STI risk

Infection and inflammation risks

›Infection and inflammation risks

›Recent gastroenteritis

›Recent URI

›Recent antibiotics

›Immunocompromise

Surgical abdomen risks

›Surgical abdomen risks

›Prior abdominal surgery

›Hernia history

›Known malrotation

›Known gallstones

Renal stone and UTI risks

›Renal stone and UTI risks

›Prior UTI

›Vesicoureteral reflux history

›Poor hydration

›High salt intake

Medication and toxin risks

›Medication and toxin risks

›NSAID use

›Iron access

›Cannabis use

›Caustic exposure

08Differential Diagnosis/ddx73

Life threatening

›Life threatening

›Malrotation with volvulus (K56.2)

›Bilious vomiting

›Rapid deterioration

›Appendicitis with perforation (K35.32)

›Migration to RLQ

›Peritonitis

›Intussusception (K56.1)

›Colicky pain episodes

›Bloody stool

›Ovarian torsion (N83.5)

›Sudden unilateral lower abdominal pain

›Vomiting

›Testicular torsion (N44)

›Scrotal pain

›High riding testis

›Ectopic pregnancy (O00.9)

›Positive pregnancy test

›Syncope or hypotension

›Diabetic ketoacidosis (E10.10)

›Abdominal pain with vomiting

›Kussmaul breathing

›Sepsis (A41.9)

›Toxic appearance

›Hypotension

Common

›Common

›Viral gastroenteritis (A08.4)

›Vomiting and diarrhea

›Sick contacts

›Constipation (K59.00)

›Infrequent stools

›Stool burden

›Mesenteric adenitis (I88.0)

›URI symptoms

›RLQ tenderness mimic

›UTI (N39.0)

›Dysuria

›Suprapubic pain

›Functional abdominal pain (R10.84)

›Normal growth

›No alarm features

›Gastritis or GERD (K29.70)

›Epigastric burning

›Relation to meals

Less common

›Less common

›Pancreatitis (K85.90)

›Epigastric pain

›Pain to back

›Cholecystitis (K81.0)

›RUQ pain

›Murphy sign

›Nephrolithiasis (N20.0)

›Colicky flank pain

›Hematuria

›Pneumonia with referred pain (J18.9)

›Cough

›Tachypnea

›Henoch Schonlein purpura (D69.0)

›Palpable purpura

›Arthralgia

›Inflammatory bowel disease (K50.90)

›Weight loss

›Bloody diarrhea

Mimics and pitfalls

›Mimics and pitfalls

›Abdominal wall pain

›Pain with tensing muscles

›Localized tenderness

›Anxiety related symptoms

›Hyperventilation

›Normal exam trend

›Early appendicitis

›Initially periumbilical pain

›Normal early labs

09Past Medical History/pmh17

Chronic conditions

›Chronic conditions

›Asthma (J45.909)

›Diabetes mellitus type 1 (E10.9)

›Sickle cell disease (D57.1)

›Inflammatory bowel disease (K50.90)

Prior similar episodes

›Prior similar episodes

›Prior appendicitis evaluation

›Prior constipation episodes

›Prior UTIs

Surgeries and procedures

›Surgeries and procedures

›Appendectomy

›Hernia repair

›Abdominal surgery history

Baseline function

›Baseline function

›Normal activity level

›Baseline diet

›Growth trajectory

10Physical Exam/exam41

General and vital signs

›General and vital signs

›Toxic appearance

›Hydration status

›Perfusion

›Mental status

Abdomen inspection and auscultation

›Abdomen inspection and auscultation

›Distension

›Visible peristalsis

›Surgical scars

›Bowel sounds

Abdomen palpation and percussion

›Abdomen palpation and percussion

›Focal tenderness location

›Guarding

›Rebound

›Rigidity

›Hepatosplenomegaly

›Mass

Peritoneal and appendicitis maneuvers

›Peritoneal and appendicitis maneuvers

›Pain with cough or hop

›Rovsing sign

›Psoas sign

›Obturator sign

Hernia and genitourinary

›Hernia and genitourinary

›Inguinal hernia exam

›Costovertebral angle tenderness

›Suprapubic tenderness

Testicular and pelvic considerations

›Testicular and pelvic considerations

›Cremasteric reflex

›Testis lie and tenderness

›Scrotal edema or erythema

›External genital exam findings

Skin and joints

›Skin and joints

›Purpura

›Urticaria

›Joint swelling

›Limp

Cardiopulmonary

›Cardiopulmonary

›Tachypnea

›Focal crackles

›Chest wall tenderness

›Murmur

11Lab Studies/labs27

Core ED labs by risk profile

›Core ED labs by risk profile

›CBC for infection or anemia concern

›Electrolytes for dehydration or vomiting

›Glucose for DKA screen

›CRP for inflammatory process support

Urine testing

›Urine testing

›Urinalysis for UTI

›Urine culture if UA suggestive

›Hematuria for stone support

Pregnancy and STI testing

›Pregnancy and STI testing

›Urine beta hCG in post menarche

›NAAT for gonorrhea

›NAAT for chlamydia

Pancreatic and hepatobiliary labs

›Pancreatic and hepatobiliary labs

›Lipase for pancreatitis

›AST

›ALT

›Bilirubin

Severe illness labs

›Severe illness labs

›Venous blood gas for acidosis

›Lactate for hypoperfusion

›Blood culture if sepsis concern

Interpretation pitfalls

›Interpretation pitfalls

›Normal WBC does not exclude appendicitis

›Early appendicitis may have normal CRP

›Ketonuria may reflect starvation

›UTI and appendicitis can coexist

12Imaging/img30

Scoring Systems

›Appendicitis risk tools

›Pediatric Appendicitis Score

›Migration of pain

›Anorexia

›Nausea or vomiting

›Fever

›RLQ tenderness

›Cough percussion hopping tenderness

›Leukocytosis

›Neutrophilia

›pARC

›Use with clinical exam and labs

›Local protocol dependent thresholds

MRI

›MRI abdomen and pelvis

›Appendicitis evaluation when ultrasound nondiagnostic

›Pregnancy or radiation avoidance priority

›Limited availability and motion sensitivity

›CT abdomen and pelvis

›Reserved for equivocal cases after ultrasound

›Contrast considerations

›Allergy history

›Renal risk

›Radiation risk higher in children

Ultrasound

›Ultrasound first line

›RLQ ultrasound for appendicitis

›Pelvic ultrasound for ovarian pathology

›Pyloric ultrasound for infant vomiting pattern

›Intussusception ultrasound for colicky pain

›False negatives with early appendicitis

›Nondiagnostic appendix common

13Special Tests/spec11

Bedside maneuvers

›Bedside maneuvers

›Carnett test for abdominal wall pain

›Jump or hop test for peritoneal irritation

›Rectal exam selective

POCUS

›POCUS

›Hydration assessment

›Bladder volume

›Free fluid screening

Procedural diagnostics

›Procedural diagnostics

›Enema reduction pathway for intussusception

›Surgical exploration pathway if volvulus suspected

14ECG/ecg11

When ECG matters in abdominal pain

›When ECG matters in abdominal pain

›Epigastric pain with risk factors

›Syncope or presyncope

›Hyperkalemia concern

High risk patterns

›High risk patterns

›ST elevation

›Wide QRS

›QT prolongation

Serial ECG logic

›Serial ECG logic

›Persistent concerning symptoms

›Evolving vitals or exam

15Assessment/ax25

Problem representation

›Problem representation

›Age

›Pain location

›Time course

›Associated symptoms

Severity and acuity

›Severity and acuity

›Hemodynamic stability

›Toxic appearance

›Hydration severity

Risk stratification

›Risk stratification

›Appendicitis score category

›Need for serial exams

›Need for surgical consult now

Working diagnoses

›Working diagnoses

›Gastroenteritis (A08.4)

›Constipation (K59.00)

›Appendicitis rule out (K35.80)

›UTI (N39.0)

Complications to exclude

›Complications to exclude

›Perforation

›Sepsis

›Dehydration with electrolyte derangement

Diagnostic uncertainty

›Diagnostic uncertainty

›Alternative diagnoses listed

›Plan for reassessment timing

16Plan/plan33

First 5 minutes

›First 5 minutes

›Airway and breathing risk

›Continuous monitoring if unstable

›IV access criteria

›If shock features then two IVs

›If difficult access then IO

›Point of care glucose if altered or vomiting

›NPO if surgical abdomen possible

Analgesia and antiemetics

›Analgesia and antiemetics

›Acetaminophen dosing per weight

›Ibuprofen dosing per weight

›Opioid for severe pain with monitoring

›Ondansetron dosing per weight

Fluids and electrolytes

›Fluids and electrolytes

›Isotonic bolus

›20 mL/kg IV

›Repeat based on perfusion

›Maintenance fluids if ongoing losses

›Electrolyte correction if abnormal

Diagnostic sequencing

›Diagnostic sequencing

›Pregnancy test early in post menarche

›UA early if urinary symptoms

›Ultrasound first line for RLQ or pelvic pain

›CT or MRI if ultrasound nondiagnostic and high suspicion

Consultations

›Consultations

›Surgery for suspected appendicitis or obstruction

›Urology for suspected torsion

›Gynecology for suspected ovarian torsion or ectopic pregnancy

Reassessment loop

›Reassessment loop

›Repeat vitals every 30 to 60 minutes if concerning

›Repeat abdominal exam after analgesia

›Track urine output

›Escalate if worsening tenderness or new guarding

17Disposition/dispo23

ICU criteria

›ICU criteria

›Shock requiring ongoing boluses

›Vasopressor requirement

›Severe DKA

Inpatient admission criteria

›Inpatient admission criteria

›Surgical diagnosis

›Persistent vomiting with dehydration

›Intractable pain

›Unsafe home observation

Observation pathway criteria

›Observation pathway criteria

›Equivocal appendicitis with stable vitals

›Serial exams planned

›Repeat imaging planned

Discharge criteria

›Discharge criteria

›Stable vitals

›Pain controlled with oral meds

›Tolerating oral fluids

›No peritoneal signs

›Reliable follow up

Follow up timing

›Follow up timing

›Primary care within 24 to 72 hours

›Earlier if symptoms persist

›Specialty follow up if indicated

18Discharge Instructions/di29

Copy discharge instructions

›Summary

›Today you were evaluated for belly pain

›Your exam and tests did not show an emergency right now

›Medicines

›Use acetaminophen for pain as directed

›Use ibuprofen only if drinking well

›Use ondansetron only as prescribed

›Eating and drinking

›Small frequent sips of fluids

›Return to regular diet as tolerated

›Activity

›Rest today

›Normal activity as tolerated

›Follow up

›See your clinician in 1 to 3 days

›Return sooner if symptoms worsen

›Return now for

›Trouble breathing

›Fainting

›Severe or worsening pain

›New pain in the right lower belly

›Green vomit

›Blood in vomit

›Blood in stool

›Fever with worsening pain

›Hard swollen belly

›Testicle pain

›Vaginal bleeding with pain

›Not peeing much

19References/r15

Guidelines and decision tools

›American College of Radiology

›ACR Appropriateness Criteria for suspected appendicitis in children

›Imaging first line ultrasound emphasis

›American Pediatric Surgical Association

›Appendicitis management guidance

›Nonoperative pathways local protocol dependent

›Pediatric Appendicitis Risk Calculator

›Risk stratification tool for suspected appendicitis

›Use with clinical judgment

›NASPGHAN

›Functional abdominal pain disorders guidance

›Alarm feature based evaluation

›Infectious Diseases Society guidance

›Pediatric UTI diagnostic and treatment principles

›Local antibiogram dependent

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.