Abdominal pain

Template

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LocationChoose oneFirst line

Red flags presentChoose any

Red flags absentChoose any

Abdominal examChoose one

GU examChoose one

Appendicitis signs presentChoose any

Appendicitis signs absentChoose any

Organs and masses presentChoose any

Organs and masses absentChoose any

DifferentialChoose any

AssessmentChoose one

LabsChoose any

ResultsChoose any

ImagingChoose any

MedicationsChoose any

DispositionChoose one

Follow-upChoose one

Follow-up reasonChoose anyJoins the line above

Counseling

Recommended supportive care with OTC medications as needed with an emphasis on hydration. Return precautions given including increasing pain, pain moving to the right lower belly, worsening fever, vomiting, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

CounselingNot in the note with these choices

Discussed the need for emergency evaluation today, and the caregiver will take the patient now. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Abdominal pain
• No weight loss, fever, night sweats, blood in the stool, bilious vomiting, joint pain, rash, or worsening pain
• Abdominal exam without guarding or rebound
• No hepatomegaly, splenomegaly, palpable mass, or distention
• No signs of a surgical abdomen
• Labs: Further testing deferred after shared decision making
• Stable for outpatient management
• Follow up if worsening or not improving

Recommended supportive care with OTC medications as needed with an emphasis on hydration. Return precautions given including increasing pain, pain moving to the right lower belly, worsening fever, vomiting, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Guarding, rebound, appendicitis signs, Murphy

Return precautions in the template

increasing painpain moving to the right lower bellyworsening fevervomitingdehydration

Sources

Few formal guidelines cover this topic, so the template also leans on expert opinion.