Chief Complaints & Ambulatory Care Console
Discriminate life threats from benign fast-track conditions across all 16 primary ED presentations: Can't-miss killers, targeted history discriminators, high-yield physical exam maneuvers, and Choosing Wisely radiation reduction rules.
Undifferentiated Abdominal Pain
High to Low AcuityViral Gastroenteritis, GERD & Peptic Dyspepsia, Constipation / Fecal Impaction, Uncomplicated Biliary Colic, Irritable Bowel Syndrome (IBS), Abdominal Wall Pain.
Onset (sudden 'pop/tear' vs gradual), migration (periumbilical to RLQ in appendicitis), relationship to meals (fatty meals in biliary colic; postprandial fear of food in mesenteric angina), flatus/bowel movements (obstipation in SBO), LMP / beta-hCG in all females of childbearing age, and anticoagulant use (rectus sheath hematoma).
Carnett's test (increased tenderness when tensing rectus = abdominal wall pain; decreased = intra-abdominal), Murphy's sign (inspiratory arrest on RUQ palpation), McBurney's / Rovsing's / Psoas signs, peritoneal guarding/rebound, femoral and inguinal hernia orifices, and testicular examination in all males.
Carnett-positive abdominal wall pain requires ZERO CT imaging. Young non-toxic patients with classic gastroenteritis need no labs or CT. Low-risk biliary colic gets right upper quadrant ultrasound, not CT abdomen.
Chest Pain (Low-Risk, MSK & Non-Ischemic)
Rule-Out Lethal 6Costochondritis (Tietze Syndrome), Chest Wall Musculoskeletal Strain, GERD & Acid Reflux, Esophageal Spasm, Anxiety / Panic Disorder, Precordial Catch Syndrome.
Character (pressure/crushing vs sharp/pleuritic/positional), radiation (jaw/left arm vs interscapular back), reproducibility with palpation or arm movement, fever/cough, dysphagia/vomiting prior to pain, and cocaine or sympathomimetic use.
Reproducible focal costochondral tenderness (reproduction of identical pain strongly suggests musculoskeletal etiology), bilateral upper extremity blood pressures (diff > 20 mmHg raises dissection suspicion), heart sounds (friction rub, muffled sounds), and lung auscultation (unilateral absent breath sounds).
HEART Score 0–3 with normal ECG and negative serial high-sensitivity troponin has < 1.7% 30-day MACE risk; safe for outpatient primary care / cardiology follow-up without inpatient admission. Zero D-dimer if PERC rule is completely negative in low-probability PE.
Shortness of Breath & Dyspnea
Respiratory Distress SpectrumAcute Uncomplicated Bronchitis, Mild Intermittent Asthma, Hyperventilation Syndrome / Respiratory Alkalosis, Vocal Cord Dysfunction (VCD), Post-Viral Cough Syndrome, Deconditioning.
Sudden vs gradual onset, orthopnea and paroxysmal nocturnal dyspnea (PND), leg swelling, hemoptysis, inhaler response, carpopedal spasm and circumoral tingling (hyperventilation), and travel / immobilization / estrogen history.
Work of breathing (accessory muscle use, tripod positioning, inability to speak full sentences), stridor (upper airway obstruction), wheezing vs crackles/rales, elevated JVP, bilateral lower extremity pitting edema, and chest wall excursion.
If clinical probability of PE is low and all 8 PERC criteria are satisfied, PE risk is < 1.4%; zero D-dimer or CTA chest is indicated. Acute bronchitis in immunocompetent non-elderly patients requires ZERO antibiotics.
Acute Headache (Primary & Benign Spectrum)
Thunderclap to BenignMigraine without Aura, Tension-Type Headache, Cluster Headache, Medication Overuse / Rebound Headache, Occipital Neuralgia, Sinusitis Headache.
Time to peak intensity ('thunderclap' reaching max in < 1 minute mandates SAH workup), fever, neck stiffness, jaw claudication / visual loss in patients > 50 yo (temporal arteritis), pregnancy / postpartum state, and prior identical headache history.
Complete neurological exam (cranial nerves, pronator drift, cerebellar testing), meningeal signs (Kernig, Brudzinski, nuchal rigidity), temporal artery tenderness/induration, eye exam with tonometry (IOP > 30 mmHg in acute glaucoma), and fundoscopy (papilledema).
Ottawa SAH Rule: Patients with non-traumatic headache peaking within 1 hour who have none of the 6 high-risk criteria do not require emergency neuroimaging or lumbar puncture. Recurrent identical migraines with normal neuro exam need NO CT head.
Altered Mental Status & Acute Intoxication
High Acuity TriageUncomplicated Acute Alcohol Intoxication (approaching clinical sobriety), Post-ictal Confusion (returning to baseline with known epilepsy), Mild Dehydration, Baseline Dementia without acute focal deficit.
Baseline cognitive function (from family/nursing home), time last seen normal, access to medications (insulin, sulfonylureas, sedatives, opioids, TCAs), fever, head trauma, and history of alcohol withdrawal / seizures.
Immediate fingerstick blood glucose (FIRST step in every AMS patient), pupillary size and reactivity (pinpoint in opioids/pontine stroke; mydriatic in sympathomimetics/anticholinergics), respiratory rate and tidal volume, skin turgor and temperature, and focal neurologic deficits.
Routine CT head is not indicated for acute uncomplicated alcohol intoxication in alert, cooperative patients without focal deficits, signs of trauma, or coagulopathy. Always administer IV Thiamine 100–500 mg BEFORE or concurrently with IV dextrose in malnourished patients.
Dizziness & Vertigo (Peripheral vs Central)
Diagnostic DiscriminationBenign Paroxysmal Positional Vertigo (BPPV), Vestibular Neuritis / Labyrinthitis, Orthostatic Hypotension, Medication-Induced Dizziness, Dehydration.
Differentiate vertigo (spinning room) vs presyncope (feeling faint/blacking out) vs disequilibrium (unsteady gait) vs lightheadedness. Constant ongoing symptoms vs brief episodes triggered only by head turns (< 60s in BPPV). Neck pain / trauma (vertebral dissection).
HINTS exam in continuous acute vestibular syndrome: Head Impulse (abnormal saccade = peripheral; normal = central stroke!), Nystagmus (direction-fixed horizontal = peripheral; direction-changing or vertical = central), Test of Skew (vertical ocular misalignment = central). Dix-Hallpike for episodic positional vertigo (torsional upbeating nystagmus = posterior canal BPPV).
HINTS exam performed by trained clinicians is MORE sensitive than early MRI (< 48h) for posterior circulation stroke. BPPV is treated with bedside Epley canalith repositioning; vestibular suppressants (meclizine) should NOT be prescribed long-term.
Low Back & Musculoskeletal Joint Pain
Fast Track / OrthoAcute Lumbosacral Muscular Strain, Mechanical Sciatica / Lumbar Radiculopathy, Inversion Ankle Sprain, Subacromial Bursitis / Rotator Cuff Tendinopathy, Acute Gout Flare, Osteoarthritis Flare.
Red flags: bowel/bladder incontinence, saddle anesthesia, progressive lower extremity bilateral motor weakness, IV drug use, fever/chills, recent spinal instrumentation, and history of cancer (malignant spinal cord compression).
Gait and lower extremity strength (L4 dorsiflexion, L5 great toe extension, S1 plantarflexion), straight leg raise (positive between 30–70 deg for radiculopathy), rectal tone / post-void bladder residual (> 200 mL strongly correlates with cauda equina), Ottawa Ankle/Knee assessment.
Choosing Wisely: Zero radiographs or MRI indicated for acute low back pain < 6 weeks in the absence of red flags. Acute ankle injuries with zero tenderness over malleolar bones and ability to bear 4 steps require NO X-rays.
Dysphagia & Odynophagia
Airway & Obstruction RiskPill-Induced Esophagitis (doxycycline, NSAIDs, iron, KCl), Reflux Esophagitis / GERD, Globus Sensation, Eosinophilic Esophagitis (EoE), Aphthous Stomatitis, Oral Candidiasis.
Inability to manage own secretions / drooling (indicates complete obstruction), button battery ingestion (true surgical emergency requiring immediate removal < 2 hours), meat bolus ingestion, medication swallowing without water, and prior strictures/rings.
Evaluate secretional handling: can patient swallow own saliva? Pharyngeal inspection for tonsillar asymmetry, uvular deviation, hot potato voice, or floor of mouth induration (Ludwig). Palpate neck for surgical subcutaneous crepitus (perforation).
Complete food impaction (inability to swallow secretions) requires emergent endoscopy within 6 hours to prevent pressure necrosis. Partial obstruction tolerating fluids can be observed and worked up electively. Glucagon IV has high failure rates and causes vomiting.
Dysuria, Flank Pain & Hematuria
Renal & GU SpectrumUncomplicated Acute Bacterial Cystitis, Simple Ureteral Colic (< 5 mm stone without infection), Interstitial Cystitis, Honeymoon Cystitis, Urethritis / Sexually Transmitted Infections.
Fever, rigors, flank vs suprapubic pain, colicky waxing/waning pain radiating to groin/labia/testicle, gross hematuria, prior stone history, and urinary retention.
Costovertebral angle (CVA) tenderness, abdominal palpation for pulsatile mass (AAA!), genital examination for perineal erythema/crepitus/pain out of proportion (Fournier gangrene), and vital signs for systemic toxicity.
In young patients with known recurrent nephrolithiasis and uncomplicated symptoms without fever or intractable vomiting, low-dose non-contrast CT can be deferred or replaced with bedside renal POCUS to assess hydronephrosis.
Dermatologic Rashes & Lesions
Fast Track to Derm CrisesContact Dermatitis (Poison Ivy / Rhus), Pityriasis Rosea (Herald patch, Christmas tree distribution), Tinea Corporis / Cruris, Acute Uncomplicated Urticaria, Herpes Zoster (Shingles, non-ophthalmic), Eczema / Atopic Dermatitis flare.
New medication exposures in past 2–8 weeks (antibiotics, anticonvulsants, allopurinol), fever, mucous membrane pain (eyes, mouth, genitals), outdoor exposures, tick bites, and personal or family history of psoriasis/atopy.
Mucosal involvement (lips, conjunctiva, oral ulceration = SJS/TEN danger!), Nikolsky sign (epidermal sheet detachment with gentle lateral pressure), palpable purpura (vasculitis / meningococcemia), skin tenderness out of proportion to erythema (necrotizing infection).
Simple contact dermatitis requires a 2–3 week oral prednisone taper (start 40–60 mg/day); courses < 10 days risk severe rebound dermatitis. Antihistamines alone do not resolve contact dermatitis.
Eye Pain, Redness & Visual Complaints
Vision PreservationViral Conjunctivitis (Pink Eye), Bacterial Conjunctivitis (non-contact lens), Subconjunctival Hemorrhage (asymptomatic blood pooling after cough), Blepharitis / Meibomian Gland Dysfunction, Hordeolum (Stye) & Chalazion, Simple Dry Eye.
Visual changes (loss of vision, blurriness, halos around lights, floaters/curtains), contact lens wear (sleeping in lenses mandates pseudomonal ulcer rule-out), foreign body / grinding / metal-on-metal history, photophobia, and discharge type.
ALWAYS check Visual Acuity FIRST. Assess pupil reactivity and symmetry (fixed mid-dilated in glaucoma; teardrop pupil in open globe). Slit lamp with fluorescein staining (dendritic pattern in HSV keratitis; Seidel sign in ruptured globe). Measure intraocular pressure (IOP) if angle closure suspected.
Never prescribe topical ophthalmic anesthetic drops (tetracaine/proparacaine) for outpatient home use—causes severe corneal melting and permanent blindness! Subconjunctival hemorrhage with normal acuity and painless eye needs ZERO medication.
Sore Throat & ENT Complaints
Airway vs OutpatientViral Pharyngitis (Rhinovirus, Adenovirus, EBV Mononucleosis), Group A Streptococcal Pharyngitis, Acute Otitis Media, Otitis Externa (Swimmer's Ear), Cerumen Impaction, Acute Aphthous Ulcer.
Inability to swallow secretions / drooling, difficulty opening mouth (trismus), change in voice quality ('hot potato voice'), neck stiffness, cough (absence favors bacterial Strep), and contact with sick individuals.
Oropharyngeal inspection: tonsillar exudates, palatal petechiae, uvular deviation (away from abscess side in PTA), trismus (measuring inter-incisor distance < 3 fingers), submandibular induration, and anterior cervical lymphadenopathy.
Modified Centor Score: patients with score 0–1 should NOT receive rapid strep testing or antibiotics (viral etiology). Score 2–3 gets rapid antigen detection; score 4 empiric or tested treatment. Amoxicillin causes rash in Epstein-Barr mononucleosis.
Gynecologic Pelvic Pain & Vaginal Bleeding
Pregnancy & Surgical RiskPrimary Dysmenorrhea, Mittelschmerz (ovulatory mid-cycle pain), Uncomplicated Ruptured Follicular Cyst, Vaginitis (Candida, Bacterial Vaginosis, Trichomoniasis), Endometriosis Flare, Early Threatened Abortion (closed os).
LMP and menstrual history, sexual history / contraception, fever, abnormal discharge, bleeding volume (soaking > 2 pads/hour for 2 consecutive hours indicates heavy bleeding), and dizziness/syncope.
MANDATORY qualitative urine beta-hCG in all females of reproductive age! Speculum examination: open vs closed cervical os, active products of conception in os, cervical motion tenderness (chandelier sign in PID), and bimanual adnexal tenderness/mass.
A negative urine beta-hCG virtually excludes ectopic pregnancy. Normal pelvic ultrasound does NOT exclude early ovarian torsion (intermittent torsion can maintain arterial flow on Doppler!).
Scrotal & Testicular Pain
Organ Viability WindowAcute Epididymitis / Epididymo-orchitis, Torsion of Appendix Testis (Blue Dot Sign), Varicocele ('Bag of Worms'), Hydrocele, Spermatocele, Post-Vasectomy Pain Syndrome.
Sudden onset of severe pain (torsion) vs gradual onset over days with dysuria/discharge (epididymitis), preceding trauma, lifting/straining, history of cryptorchidism, and sexual history.
Cremasteric reflex (elevation of ipsilateral testicle with medial thigh stroke; ABSENT in > 95% of testicular torsion!), testicular lie (horizontal/high-riding in torsion), Prehn sign (pain relief with elevation; unreliable!), and localized tender blue nodule at superior pole (appendix testis).
If acute testicular torsion is strongly suspected clinically, stat urology consultation and surgical exploration should NOT be delayed for ultrasound imaging. Manual detorsion ('opening a book' outward rotation) can be attempted while awaiting OR.
Palpitations & Transient Arrhythmias
Hemodynamic StabilityPremature Ventricular Contractions (PVCs), Premature Atrial Contractions (PACs), Sinus Tachycardia (caffeine, anxiety, nicotine, fever, dehydration), Non-Pre-excited Paroxysmal SVT (stable).
Onset (abrupt flip of a switch vs gradual acceleration), associated presyncope or syncope, family history of sudden unexplained cardiac death < 40 yo, thyroid disease, caffeine, alcohol ('holiday heart'), stimulant, or decongestant intake.
Immediate 12-lead ECG. Assess hemodynamic stability: SBP < 90 mmHg, acute altered mental status, ongoing ischemic chest pain, or acute pulmonary edema mandates immediate electrical synchronized cardioversion.
Isolated PVCs or PACs on 12-lead ECG in asymptomatic or mildly symptomatic patients with normal vitals and zero syncope require NO admission or emergency workup. Reassurance, reduction in stimulants, and outpatient Holter monitor referral are standard.
Acute Nausea, Vomiting & Diarrhea
Hydration & Surgical TriageAcute Viral Gastroenteritis (Norovirus, Rotavirus), Staphylococcal or B. cereus Pre-Formed Toxin Food Poisoning, Traveler's Diarrhea (non-dysenteric), Cannabinoid Hyperemesis Syndrome (hot shower relief), Mild Dehydration.
Bloody diarrhea (dysentery), duration > 7 days, sick contacts / common meal exposure, antibiotic use in prior 3 months (C. diff), daily heavy cannabis use, ability to keep fluids down, and urination frequency.
Volume status assessment (orthostatic vitals, dry mucous membranes, delayed capillary refill), abdominal softness vs focal tenderness, peritoneal signs, surgical scars, and hernia orifices.
Oral rehydration therapy with small frequent volumes (5–10 mL sips q5m after Ondansetron) is clinically equivalent to IV hydration and prevents unnecessary IV cannulation. Stool cultures are not indicated for acute non-bloody diarrhea < 7 days.