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Right Lower Quadrant PainAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

600 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/hx86

Context and trajectory

›Symptom context

›Time course

›Baseline health before onset

›First episode

›Recurrent episodes

›Prior similar evaluation

›Current symptom trajectory

Onset

›Onset features

›Sudden onset

›Gradual onset

›Initial pain location

›Migration to right lower quadrant

Provocation/Palliation

›Provoking factors

›Movement

›Coughing

›Bumps in car ride

›Urination

›Bowel movement

›Eating

›Relieving factors

›Stillness

›Analgesics taken

›Antiemetics taken

Quality

›Pain quality

02Alarm Features/alarm27

Immediate escalation triggers

›High risk physiology

›Systolic blood pressure under 90 mmHg

›Heart rate at least 120 beats per minute

›Respiratory rate at least 24 breaths per minute

›Oxygen saturation under 92 percent on room air

›Temperature at least 38.5 C

›Altered mental status

›High risk abdominal findings

›Peritonitis

›Rebound tenderness

›Involuntary guarding

›Rigid abdomen

›Distension with vomiting

›Severe pain out of proportion

›High risk historical features

›Syncope

›Sudden maximal pain at onset

›Persistent vomiting with dehydration

›Immunocompromised state

›Anticoagulation use

›Pregnancy and gonadal threats

›Positive pregnancy test with pain

›Heavy vaginal bleeding

›Severe unilateral pelvic pain

›Sudden testicular pain

›High riding testis

›Absent cremasteric reflex

03Medications/meds24

Medication exposures and interactions

›Analgesics and antipyretics

›NSAIDs

›Acetaminophen

›Opioids

›Anticoagulants and antiplatelets

›Warfarin

›Direct oral anticoagulants

›Heparins

›Aspirin

›P2Y12 inhibitors

›Recent antibiotics

›Within last 30 days

›C difficile risk exposure

›Hormonal and reproductive medications

›Oral contraceptives

›IUD

›Fertility treatments

›High risk medication classes

›Steroids

›SGLT2 inhibitors

›Immunosuppressants

›Contrast related risk modifiers

›Metformin

›Prior contrast reaction

04Diet/diet19

Intake and exposures

›Recent intake pattern

›Poor oral intake

›Normal intake

›Recent heavy meal

›Recent fasting

›Hydration indicators

›Reduced urine output

›Thirst

›Orthostatic symptoms

›Foodborne exposure risks

›Undercooked meat

›Unpasteurized foods

›Sick contacts with gastroenteritis

›Caffeine and stimulant exposure

›High caffeine intake

›Energy drinks

›Alcohol exposure

›Recent binge

›Daily use pattern

05Review of Systems/ros31

System review

›General

›Fever

›Chills

›Weight loss

›Fatigue

›Gastrointestinal

›Nausea

›Vomiting

›Diarrhea

›Constipation

›Obstipation

›Bloody stool

›Genitourinary

›Dysuria

›Frequency

›Hematuria

›Flank pain

›Gynecologic

›Vaginal bleeding

›Vaginal discharge

›Pelvic pain

›Missed period

›Respiratory and cardiovascular

›Chest pain

›Dyspnea

›Palpitations

›Syncope

06Collateral History and Family History/chafh14

Context and inherited risks

›Collateral source

›Family report

›Caregiver report

›EMS report

›Reliability concerns

›Family history relevant to right lower quadrant pain

›Inflammatory bowel disease

›Colorectal cancer

›Nephrolithiasis

›Thrombophilia

›Exposure context

›Household gastroenteritis

›Recent travel exposure

›Foodborne outbreak exposure

07Risk Factors/rf28

Patient and exposure risks

›Appendicitis and perforation risk

›Symptom duration over 48 hours

›Immunosuppression

›Older age

›Gynecologic infection risk

›New sexual partner

›Prior PID

›No barrier contraception

›IUD insertion recent

›Ectopic pregnancy risk

›Prior ectopic pregnancy

›Prior tubal surgery

›Prior PID

›Assisted reproduction

›Nephrolithiasis risk

›Prior stones

›Low fluid intake

›High heat exposure

›Hernia risk

›Prior hernia

›Heavy lifting

›Prior abdominal surgery

›Vascular catastrophe risk

›Known aortic aneurysm

›Marfan syndrome

›Ehlers Danlos syndrome

›Cocaine or stimulant use

08Differential Diagnosis/ddx91

Life threatening

›Cannot miss causes

›Appendicitis with perforation or abscess (K35.2)

›Worsening pain

›Peritonitis

›Fever

›Leukocytosis

›Ectopic pregnancy (O00.9)

›Positive pregnancy test

›Vaginal bleeding

›Syncope

›Shoulder pain

›Ovarian torsion (N83.5)

›Sudden severe unilateral pelvic pain

›Nausea

›Adnexal mass risk

›Testicular torsion (N44)

›Sudden testicular pain

›High riding testis

›Absent cremasteric reflex

›Bowel obstruction with ischemia (K56.6)

›Distension

›Persistent vomiting

›Obstipation

›Peritonitis

›Mesenteric ischemia (K55.9)

›Pain out of proportion

›Lactate elevation

09Past Medical History/pmh20

Prior conditions and procedures

›Relevant chronic conditions

›Inflammatory bowel disease

›Prior appendicitis

›Prior nephrolithiasis

›Recurrent urinary tract infections

›Prior PID

›Known ovarian cysts

›Known abdominal aortic aneurysm

›Surgeries and procedures

›Prior abdominal surgery

›Prior hernia repair

›Prior cesarean delivery

›Prior tubal surgery

›Baseline status

›Baseline bowel pattern

›Baseline urinary pattern

›Baseline pain tolerance

›Devices

›Intrauterine device

›Ureteral stent

10Physical Exam/exam51

Initial appearance and vitals

›General assessment

›Ill appearance

›Toxic appearance

›Diaphoresis

›Dehydration signs

›Vital sign interpretation

›Fever pattern

›Tachycardia disproportionate

›Hypotension

›Orthostasis

Abdominal exam

›Inspection and auscultation

›Distension

›Surgical scars

›Bowel sounds absent

›Bowel sounds high pitched

›Palpation and percussion

›Right lower quadrant tenderness

›McBurney point tenderness

›Rebound tenderness

›Guarding

›Percussion tenderness

›Mass

›Peritoneal maneuvers

›Rovsing sign

›Psoas sign

›Obturator sign

11Lab Studies/labs24

Core labs

›Inflammatory and infection evaluation

›CBC

›Neutrophilia interpretation

›CRP

›Procalcitonin local protocol dependent

›Metabolic evaluation

›Electrolytes

›Creatinine for contrast planning

›Liver enzymes for alternative diagnosis

›Pregnancy evaluation

›Urine pregnancy test

›Serum beta hCG if pregnancy suspected

›Urinary evaluation

›Urinalysis

›Urine microscopy for hematuria

›Urine culture triggers

Sepsis and ischemia evaluation

›Perfusion markers when high risk

›Lactate

›Venous blood gas when shock suspected

›Blood cultures when febrile and toxic

Gynecologic and STI evaluation

›Infection testing when indicated

›NAAT for gonorrhea

›NAAT for chlamydia

›Vaginal wet mount local protocol dependent

12Imaging/img39

Scoring Systems

›Appendicitis risk scores for selection of imaging and consultation

›Alvarado score

›Low risk range supports observation and alternative diagnosis workup

›Intermediate risk supports imaging

›High risk supports early surgical consultation

›Appendicitis Inflammatory Response score

›Intermediate risk supports imaging

›High risk supports early surgical consultation

›Pediatric Appendicitis Score

›Use in pediatrics and adolescents

›Avoid using score alone to rule out appendicitis

MRI

›MRI abdomen pelvis for appendicitis

›Pregnancy with equivocal ultrasound

›Contrast avoidance considerations

›Limitations

›Availability dependent

›CT abdomen pelvis for appendicitis and complications

›IV contrast protocol for suspected appendicitis

›Oral contrast usually not required local protocol dependent

›Findings supporting appendicitis

›Findings supporting perforation

›CT for urinary stone evaluation

›Noncontrast CT when ureterolithiasis likely

›Radiation reduction protocols when available

›CT angiography for vascular catastrophe when suspected

13Special Tests/spec14

Bedside maneuvers and procedural diagnostics

›Abdominal wall pain evaluation

›Carnett sign supportive of abdominal wall source

›Focal superficial tenderness pattern

›Pelvic infection evaluation

›Cervical motion tenderness significance

›Uterine tenderness significance

›Adnexal tenderness significance

›Testicular torsion evaluation

›Manual detorsion only if immediate ultrasound and surgery delayed local protocol dependent

›Emergent urology consultation triggers

Point of care ultrasound

›Focused POCUS targets

›Free fluid in pelvis

›Hydronephrosis

›Abdominal aorta screening in appropriate age and risk

14ECG/ecg10

When ECG changes management

›Indications in right lower quadrant pain

›Older age

›Significant tachycardia

›Syncope

›Chest pain

›Severe electrolyte abnormality risk from vomiting

›High risk ECG patterns

›Ischemic ST changes

›Hyperkalemia patterns

›Prolonged QT interval with antiemetic use risk

15Assessment/ax17

Problem synthesis and risk stratification

›Working diagnosis selection

›Appendicitis concern with risk tiering

›Renal colic concern with complication screen

›Gynecologic emergency concern with pregnancy status

›Severity stratification

›Peritonitis present

›Sepsis physiology present

›Uncontrolled pain

›Persistent vomiting with dehydration

›Complications to exclude

›Appendiceal perforation or abscess

›Ectopic pregnancy rupture

›Ovarian torsion necrosis risk

›Obstruction with ischemia

›Diagnostic uncertainty handling

›Observation pathway with repeat exams

›Repeat labs and imaging triggers

16Plan/plan43

Differential Management

›!Appendicitis→›!Ectopic pregnancy→›Ovarian torsion→

First 5 minutes and stabilization

›Immediate priorities

›Cardiac monitor when unstable

›Two large bore IV when shock suspected

›Crystalloid bolus if hypotensive

›NPO if surgical abdomen possible

›Analgesia and antiemetics

›Acetaminophen PO or IV dosing per local protocol

›NSAID if renal function acceptable and no bleeding risk

›Opioid for severe pain with reassessment loop

›Ondansetron dosing per local protocol

Diagnostic sequencing

›Pregnancy first approach for people who can be pregnant

›Urine pregnancy test early

›Immediate ultrasound pathway if positive pregnancy test and pain

›Appendicitis pathway

›Risk score to guide imaging and consultation

›Ultrasound first in children and pregnancy when feasible

›CT abdomen pelvis when ultrasound nondiagnostic and suspicion persists

›Renal colic pathway

›Urinalysis for hematuria and infection

›Imaging selection based on risk and pregnancy

›Infection with obstruction triggers emergent urology consultation

17Disposition/dispo21

Level of care and follow up criteria

›ICU or resuscitation area criteria

›Shock requiring ongoing fluid resuscitation or vasopressors

›Sepsis with organ dysfunction

›Altered mental status

›Inpatient admission criteria

›Suspected appendicitis

›Complicated diverticulitis

›Pyelonephritis with instability

›Inability to tolerate oral intake

›Uncontrolled pain requiring parenteral therapy

›Observation pathway criteria

›Intermediate appendicitis risk with equivocal imaging

›Need for serial exams

›Need for repeat labs

›Discharge criteria

›Stable vitals

›Pain controlled on oral regimen

›Tolerating oral fluids

›No peritoneal signs

›Reliable follow up

›Clear return precautions provided

18Discharge Instructions/di25

Copy discharge instructions

›What we think is happening

›Your pain may be from a condition that can change over time

›Some serious causes may not show early

›Medications

›Take prescribed pain medicine only as directed

›Do not drive after sedating medicines

›Avoid NSAIDs if you were told you have kidney problems or bleeding risk

›Fluids and food

›Drink enough fluids to keep urine light yellow unless you were told to limit fluids

›Start with small bland meals as tolerated

›Follow up

›Follow up with your primary care clinician within 24 to 72 hours

›Follow up sooner if symptoms worsen

›Return to emergency care now if any of these happen

›Worsening belly pain

›New severe pain

›Fainting

›Fever

›Repeated vomiting

›Black stool

›Bloody stool

›New vaginal bleeding

›New testicular pain

›New chest pain

›Shortness of breath

19References/r16

Guidelines and decision tools

›American College of Radiology Appropriateness Criteria Right Lower Quadrant Pain Suspected Appendicitis

›Imaging selection across adult and pediatric populations

›Pregnancy imaging pathways included

›World Society of Emergency Surgery guidelines for acute appendicitis 2020

›Risk stratification

›Imaging strategy

›Antibiotic and operative pathways

›American College of Obstetricians and Gynecologists guidance on ectopic pregnancy evaluation and management

›Ultrasound and beta hCG interpretation

›Time critical consultation triggers

›American Urological Association guideline for ureteral stones

›Analgesia and medical expulsive therapy context

›Indications for urgent intervention

›American College of Emergency Physicians clinical policy topics on abdominal pain imaging and evaluation local protocol dependent

›CT use considerations

›Shared decision making when low risk

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.

Right Lower Quadrant PainAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

600 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/hx86

Context and trajectory

›Symptom context

›Time course

›Baseline health before onset

›First episode

›Recurrent episodes

›Prior similar evaluation

›Current symptom trajectory

Onset

›Onset features

›Sudden onset

›Gradual onset

›Initial pain location

›Migration to right lower quadrant

Provocation/Palliation

›Provoking factors

›Movement

›Coughing

›Bumps in car ride

›Urination

›Bowel movement

›Eating

›Relieving factors

›Stillness

›Analgesics taken

›Antiemetics taken

Quality

›Pain quality

02Alarm Features/alarm27

Immediate escalation triggers

›High risk physiology

›Systolic blood pressure under 90 mmHg

›Heart rate at least 120 beats per minute

›Respiratory rate at least 24 breaths per minute

›Oxygen saturation under 92 percent on room air

›Temperature at least 38.5 C

›Altered mental status

›High risk abdominal findings

›Peritonitis

›Rebound tenderness

›Involuntary guarding

›Rigid abdomen

›Distension with vomiting

›Severe pain out of proportion

›High risk historical features

›Syncope

›Sudden maximal pain at onset

›Persistent vomiting with dehydration

›Immunocompromised state

›Anticoagulation use

›Pregnancy and gonadal threats

›Positive pregnancy test with pain

›Heavy vaginal bleeding

›Severe unilateral pelvic pain

›Sudden testicular pain

›High riding testis

›Absent cremasteric reflex

03Medications/meds24

Medication exposures and interactions

›Analgesics and antipyretics

›NSAIDs

›Acetaminophen

›Opioids

›Anticoagulants and antiplatelets

›Warfarin

›Direct oral anticoagulants

›Heparins

›Aspirin

›P2Y12 inhibitors

›Recent antibiotics

›Within last 30 days

›C difficile risk exposure

›Hormonal and reproductive medications

›Oral contraceptives

›IUD

›Fertility treatments

›High risk medication classes

›Steroids

›SGLT2 inhibitors

›Immunosuppressants

›Contrast related risk modifiers

›Metformin

›Prior contrast reaction

04Diet/diet19

Intake and exposures

›Recent intake pattern

›Poor oral intake

›Normal intake

›Recent heavy meal

›Recent fasting

›Hydration indicators

›Reduced urine output

›Thirst

›Orthostatic symptoms

›Foodborne exposure risks

›Undercooked meat

›Unpasteurized foods

›Sick contacts with gastroenteritis

›Caffeine and stimulant exposure

›High caffeine intake

›Energy drinks

›Alcohol exposure

›Recent binge

›Daily use pattern

05Review of Systems/ros31

System review

›General

›Fever

›Chills

›Weight loss

›Fatigue

›Gastrointestinal

›Nausea

›Vomiting

›Diarrhea

›Constipation

›Obstipation

›Bloody stool

›Genitourinary

›Dysuria

›Frequency

›Hematuria

›Flank pain

›Gynecologic

›Vaginal bleeding

›Vaginal discharge

›Pelvic pain

›Missed period

›Respiratory and cardiovascular

›Chest pain

›Dyspnea

›Palpitations

›Syncope

06Collateral History and Family History/chafh14

Context and inherited risks

›Collateral source

›Family report

›Caregiver report

›EMS report

›Reliability concerns

›Family history relevant to right lower quadrant pain

›Inflammatory bowel disease

›Colorectal cancer

›Nephrolithiasis

›Thrombophilia

›Exposure context

›Household gastroenteritis

›Recent travel exposure

›Foodborne outbreak exposure

07Risk Factors/rf28

Patient and exposure risks

›Appendicitis and perforation risk

›Symptom duration over 48 hours

›Immunosuppression

›Older age

›Gynecologic infection risk

›New sexual partner

›Prior PID

›No barrier contraception

›IUD insertion recent

›Ectopic pregnancy risk

›Prior ectopic pregnancy

›Prior tubal surgery

›Prior PID

›Assisted reproduction

›Nephrolithiasis risk

›Prior stones

›Low fluid intake

›High heat exposure

›Hernia risk

›Prior hernia

›Heavy lifting

›Prior abdominal surgery

›Vascular catastrophe risk

›Known aortic aneurysm

›Marfan syndrome

›Ehlers Danlos syndrome

›Cocaine or stimulant use

08Differential Diagnosis/ddx91

Life threatening

›Cannot miss causes

›Appendicitis with perforation or abscess (K35.2)

›Worsening pain

›Peritonitis

›Fever

›Leukocytosis

›Ectopic pregnancy (O00.9)

›Positive pregnancy test

›Vaginal bleeding

›Syncope

›Shoulder pain

›Ovarian torsion (N83.5)

›Sudden severe unilateral pelvic pain

›Nausea

›Adnexal mass risk

›Testicular torsion (N44)

›Sudden testicular pain

›High riding testis

›Absent cremasteric reflex

›Bowel obstruction with ischemia (K56.6)

›Distension

›Persistent vomiting

›Obstipation

›Peritonitis

›Mesenteric ischemia (K55.9)

›Pain out of proportion

›Lactate elevation

09Past Medical History/pmh20

Prior conditions and procedures

›Relevant chronic conditions

›Inflammatory bowel disease

›Prior appendicitis

›Prior nephrolithiasis

›Recurrent urinary tract infections

›Prior PID

›Known ovarian cysts

›Known abdominal aortic aneurysm

›Surgeries and procedures

›Prior abdominal surgery

›Prior hernia repair

›Prior cesarean delivery

›Prior tubal surgery

›Baseline status

›Baseline bowel pattern

›Baseline urinary pattern

›Baseline pain tolerance

›Devices

›Intrauterine device

›Ureteral stent

10Physical Exam/exam51

Initial appearance and vitals

›General assessment

›Ill appearance

›Toxic appearance

›Diaphoresis

›Dehydration signs

›Vital sign interpretation

›Fever pattern

›Tachycardia disproportionate

›Hypotension

›Orthostasis

Abdominal exam

›Inspection and auscultation

›Distension

›Surgical scars

›Bowel sounds absent

›Bowel sounds high pitched

›Palpation and percussion

›Right lower quadrant tenderness

›McBurney point tenderness

›Rebound tenderness

›Guarding

›Percussion tenderness

›Mass

›Peritoneal maneuvers

›Rovsing sign

›Psoas sign

›Obturator sign

11Lab Studies/labs24

Core labs

›Inflammatory and infection evaluation

›CBC

›Neutrophilia interpretation

›CRP

›Procalcitonin local protocol dependent

›Metabolic evaluation

›Electrolytes

›Creatinine for contrast planning

›Liver enzymes for alternative diagnosis

›Pregnancy evaluation

›Urine pregnancy test

›Serum beta hCG if pregnancy suspected

›Urinary evaluation

›Urinalysis

›Urine microscopy for hematuria

›Urine culture triggers

Sepsis and ischemia evaluation

›Perfusion markers when high risk

›Lactate

›Venous blood gas when shock suspected

›Blood cultures when febrile and toxic

Gynecologic and STI evaluation

›Infection testing when indicated

›NAAT for gonorrhea

›NAAT for chlamydia

›Vaginal wet mount local protocol dependent

12Imaging/img39

Scoring Systems

›Appendicitis risk scores for selection of imaging and consultation

›Alvarado score

›Low risk range supports observation and alternative diagnosis workup

›Intermediate risk supports imaging

›High risk supports early surgical consultation

›Appendicitis Inflammatory Response score

›Intermediate risk supports imaging

›High risk supports early surgical consultation

›Pediatric Appendicitis Score

›Use in pediatrics and adolescents

›Avoid using score alone to rule out appendicitis

MRI

›MRI abdomen pelvis for appendicitis

›Pregnancy with equivocal ultrasound

›Contrast avoidance considerations

›Limitations

›Availability dependent

›CT abdomen pelvis for appendicitis and complications

›IV contrast protocol for suspected appendicitis

›Oral contrast usually not required local protocol dependent

›Findings supporting appendicitis

›Findings supporting perforation

›CT for urinary stone evaluation

›Noncontrast CT when ureterolithiasis likely

›Radiation reduction protocols when available

›CT angiography for vascular catastrophe when suspected

13Special Tests/spec14

Bedside maneuvers and procedural diagnostics

›Abdominal wall pain evaluation

›Carnett sign supportive of abdominal wall source

›Focal superficial tenderness pattern

›Pelvic infection evaluation

›Cervical motion tenderness significance

›Uterine tenderness significance

›Adnexal tenderness significance

›Testicular torsion evaluation

›Manual detorsion only if immediate ultrasound and surgery delayed local protocol dependent

›Emergent urology consultation triggers

Point of care ultrasound

›Focused POCUS targets

›Free fluid in pelvis

›Hydronephrosis

›Abdominal aorta screening in appropriate age and risk

14ECG/ecg10

When ECG changes management

›Indications in right lower quadrant pain

›Older age

›Significant tachycardia

›Syncope

›Chest pain

›Severe electrolyte abnormality risk from vomiting

›High risk ECG patterns

›Ischemic ST changes

›Hyperkalemia patterns

›Prolonged QT interval with antiemetic use risk

15Assessment/ax17

Problem synthesis and risk stratification

›Working diagnosis selection

›Appendicitis concern with risk tiering

›Renal colic concern with complication screen

›Gynecologic emergency concern with pregnancy status

›Severity stratification

›Peritonitis present

›Sepsis physiology present

›Uncontrolled pain

›Persistent vomiting with dehydration

›Complications to exclude

›Appendiceal perforation or abscess

›Ectopic pregnancy rupture

›Ovarian torsion necrosis risk

›Obstruction with ischemia

›Diagnostic uncertainty handling

›Observation pathway with repeat exams

›Repeat labs and imaging triggers

16Plan/plan43

Differential Management

›!Appendicitis→›!Ectopic pregnancy→›Ovarian torsion→

First 5 minutes and stabilization

›Immediate priorities

›Cardiac monitor when unstable

›Two large bore IV when shock suspected

›Crystalloid bolus if hypotensive

›NPO if surgical abdomen possible

›Analgesia and antiemetics

›Acetaminophen PO or IV dosing per local protocol

›NSAID if renal function acceptable and no bleeding risk

›Opioid for severe pain with reassessment loop

›Ondansetron dosing per local protocol

Diagnostic sequencing

›Pregnancy first approach for people who can be pregnant

›Urine pregnancy test early

›Immediate ultrasound pathway if positive pregnancy test and pain

›Appendicitis pathway

›Risk score to guide imaging and consultation

›Ultrasound first in children and pregnancy when feasible

›CT abdomen pelvis when ultrasound nondiagnostic and suspicion persists

›Renal colic pathway

›Urinalysis for hematuria and infection

›Imaging selection based on risk and pregnancy

›Infection with obstruction triggers emergent urology consultation

17Disposition/dispo21

Level of care and follow up criteria

›ICU or resuscitation area criteria

›Shock requiring ongoing fluid resuscitation or vasopressors

›Sepsis with organ dysfunction

›Altered mental status

›Inpatient admission criteria

›Suspected appendicitis

›Complicated diverticulitis

›Pyelonephritis with instability

›Inability to tolerate oral intake

›Uncontrolled pain requiring parenteral therapy

›Observation pathway criteria

›Intermediate appendicitis risk with equivocal imaging

›Need for serial exams

›Need for repeat labs

›Discharge criteria

›Stable vitals

›Pain controlled on oral regimen

›Tolerating oral fluids

›No peritoneal signs

›Reliable follow up

›Clear return precautions provided

18Discharge Instructions/di25

Copy discharge instructions

›What we think is happening

›Your pain may be from a condition that can change over time

›Some serious causes may not show early

›Medications

›Take prescribed pain medicine only as directed

›Do not drive after sedating medicines

›Avoid NSAIDs if you were told you have kidney problems or bleeding risk

›Fluids and food

›Drink enough fluids to keep urine light yellow unless you were told to limit fluids

›Start with small bland meals as tolerated

›Follow up

›Follow up with your primary care clinician within 24 to 72 hours

›Follow up sooner if symptoms worsen

›Return to emergency care now if any of these happen

›Worsening belly pain

›New severe pain

›Fainting

›Fever

›Repeated vomiting

›Black stool

›Bloody stool

›New vaginal bleeding

›New testicular pain

›New chest pain

›Shortness of breath

19References/r16

Guidelines and decision tools

›American College of Radiology Appropriateness Criteria Right Lower Quadrant Pain Suspected Appendicitis

›Imaging selection across adult and pediatric populations

›Pregnancy imaging pathways included

›World Society of Emergency Surgery guidelines for acute appendicitis 2020

›Risk stratification

›Imaging strategy

›Antibiotic and operative pathways

›American College of Obstetricians and Gynecologists guidance on ectopic pregnancy evaluation and management

›Ultrasound and beta hCG interpretation

›Time critical consultation triggers

›American Urological Association guideline for ureteral stones

›Analgesia and medical expulsive therapy context

›Indications for urgent intervention

›American College of Emergency Physicians clinical policy topics on abdominal pain imaging and evaluation local protocol dependent

›CT use considerations

›Shared decision making when low risk

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.