Sandbox/stem

Detailed history: ❑ Age ❑ Sex ❑ Past medical history ❑ Past surgical history ❑ Occupational history travel history ❑ Travel history ❑ Medications Characterize the symptoms: Characterize the pain: ❑ Onset (eg, sudden, gradual) ❑ Provocative and palliating factors (eg, Is the pain related to your meals?) ❑ Quality (eg, dull, sharp, colicky, waxing and waning) ❑ Radiation (eg, to the shoulder, back, flank, groin, or chest) ❑ Site (eg, a particular quadrant or diffuse) ❑ Pain location may change over time, reflecting progression of disease ❑ Intensity ❑ Time course (eg, hours versus weeks, constant or intermittent) Other symptoms ❑ Nausea & vomiting ❑ Diaphoresis ❑ Anorexia ❑ Fever ❑ Bloody stool ❑ Vaginal discharge ❑ Penile discharge ❑ Painful urination ❑ Shortness of breath ❑ Altered mental status ❑ Jaundice ❑ Maldigestion ❑ Flatulence ❑ Fatigue ❑ Scrotal pain/swelling ❑ Recent trauma ❑ Mass in any of the quadrants ❑ Symptoms suggestive of sepsis ❑ Symptoms suggestive of common hepatic duct obstruction ❑ RUQ pain with fever & jaundice ❑ Symptoms suggestive of gallstone ileus ❑ Transient abdominal pain with nausea & vomiting ❑ Hematemesis

Examine the patient: ❑ Vital signs ❑ Temperature ❑ Heart rate (tachycardia) ❑ Blood pressure (hypotension) ❑ Respiratory rate (tachypnea) ❑ Skin ❑ Diaphoresis ❑ Pallor ❑ Jaundice ❑ Dehydration ❑ Inspection ❑If the patient is curled up/agitated, this is suggestive of renal colic ❑If the patient is lying still in bed with knees bent, this is suggestive of peritonitis ❑Signs of previous surgery ❑Abdominal pulsations ❑Signs of systemic disease eg, ❑Pallor, suggestive of bleeding ❑Spider angiomata, suggestive of cirrhosis ❑ Auscultation ❑ Abdominal crepitations ❑ Reduced bowel sounds ❑ Increased bowel sounds ❑ Bruit, suggestive of abdominal aortic aneurysm ❑ Palpation ❑ Rigidity ❑ Guarding ❑ Abdominal tenderness ❑ Distension ❑ Detection of masses on palpating the abdomen ❑ McBurney's point tenderness ❑ Rovsing's sign ❑ Carnett's sign ❑ Psoas sign (suggestive of retrocecal appendix) ❑ Obturator sign ❑ Cullen's sign ❑ Grey-Turner's sign ❑ Digital rectal exam (tenderness may be present in retrocecal appendicitis) ❑ Pelvic exam in females ❑ Testicular examination in males ❑ Signs of sepsis ❑ Cardiovascular system ❑ Respiratory system ❑ Anorectal (bleeding)

❑ Assess hemodynamic stability

Stable

Unstable

Order laboratory tests: ❑ Pregnancy test (required in women of child-bearing age) ❑ CBC ❑ Hematocrit ❑ Urinalysis ❑ Serum electrolytes ❑ ESR ❑ ABG ❑ D dimer ❑ Serum lactate ❑ BUN ❑ Creatinine ❑ Amylase ❑ Lipase ❑ Triglyceride ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT Order imaging studies: ❑ Order urgent trans abdominal ultrasound (TAUSG) ❑ Abdominal CT ❑ Chest x-ray ❑ Angiography

Stabilize the patient