1. Abdominal Pain • Scope of the problem • Anatomic Essentials • Visceral Pain • Parietal Pain • Referred Pain

2. History • Where is your pain? Has it always been there? • Does the pain radiate anywhere? • How did the pain begin (sudden vs. gradual onset)? How long have you had the pain? • What were you doing when the pain began? • What does the pain feel like? • On a scale of 0–10, how severe is the pain? • Does anything make the pain better or worse? • Have you had the pain before?

4. History (continued) • Associated symptoms • Gastrointestinal • Genitourinary • Gynecologic • Cardiopulmonary • Past medical

5. Physical Examination - Directed • General appearance • Vital Signs • Abdomen • Inspection • Auscultation • Percussion • Palpation

8. Physical Examination - Directed • Pelvic • Genital • Back • Rectal • Head-to-toe

9. Appendicitis Biliary colic, cholecystitis, cholangitis Bowel obstruction Diverticulitis Ectopic pregnancy Gastroenteritis Intussuception Mesenteric Ischemia Ovarian torsion Pancreatitis Pelvic Inflammatory Disease (PID) Perforated peptic ulcer Ruptured or leaking abdominal aortic aneurysm (AAA) Testicular torsion Ureteral colic Volvulus Differential Diagnosis

10. Diagnostic Testing • Laboratory Studies • CBC • Urinalysis • Pregnancy • Amylase/Lipase • Other • Electrocardiogram

11. Diagnostic Testing - continued • Radiologic Studies • Plain Films • Ultrasound • Computed Tomography

14. General Treatment Principles • Volume repletion • Pain relief • Antibiotics • Other

15. Special Patients • Elderly • Pediatric • Immune compromised

17. Disposition • Surgical consultation • Serial evaluation • Discharge

18. Do not restrict the diagnosis solely by the location of the pain. Consider appendicitis in all patients with abdominal pain and an appendix, especially in patients with the presumed diagnosis of gastroenteritis, PID or UTI. Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain. The WBC count is of little clinical value in the patient with possible appendicitis. Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative. Pain medications reduce pain and suffering without compromising diagnostic accuracy. An elderly patient with abdominal pain has a high likelihood of surgical disease. Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain. A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis; they need an operation. The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA. Pearls, Pitfalls and Myths