| Headache Type | What to Ask (Key History) | What to Look For (Physical Exam) | When to Image (SNOOP4 Rule) | Emergency Department Treatment Protocol |
|---|---|---|---|---|
| Migraine Without Aura | Unilateral, throbbing/pulsatile headache lasting 4–72 hours, aggravated by routine physical activity, accompanied by nausea, vomiting, photophobia, and phonophobia. History of identical recurrent attacks. | Completely normal neurological examination; alert and oriented; no meningismus; sharp optic disc margins on fundoscopy; no temporal artery tenderness. | Zero neuroimaging needed if typical recurrent attack with completely normal neurological exam and SNOOP4 negative. | First-line ED Migraine Cocktail: IV Ketorolac 15–30 mg + Metoclopramide 10 mg IV (or Prochlorperazine 10 mg IV) + Diphenhydramine 25 mg IV (prevents akathisia/dystonia) + Dexamethasone 10 mg IV (proven to prevent 72-hour rebound headache) + 1 L Normal Saline bolus. Avoid opioids (cause rebound medication-overuse headache). |
| Tension-Type Headache | Bilateral, non-pulsatile, dull, band-like 'vise' pressure around the forehead and occiput, mild-to-moderate intensity, not aggravated by walking or climbing stairs, NO nausea, NO photophobia. | Palpation reveals myofascial trigger points and tenderness in pericranial, trapezius, and suboccipital muscles; completely normal cranial nerve and motor exam. | Zero imaging indicated. Completely clinical diagnosis. | Oral Acetaminophen 1000 mg + Ibuprofen 400–600 mg PO, stress reduction counseling, posture correction, warm compresses to neck. |
| Cluster Headache | Excruciating, sharp, unilateral periorbital/temporal pain lasting 15 to 180 minutes, occurring multiple times per day (often waking patient from sleep). Severe agitation (patient paces room). | Ipsilateral autonomic activation during attack: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead sweating, miosis, and ptosis (partial Horner syndrome). | Neuroimaging (MRI/MRA brain) recommended on first presentation to rule out cavernous sinus pathology or carotid dissection. | 100% High-Flow Oxygen (12–15 L/min via non-rebreather mask for 15 minutes; highly effective in 70% of patients) + Subcutaneous Sumatriptan 6 mg (or intranasal Zolmitriptan 5 mg). Discharge with oral Verapamil prophylaxis. |
| Medication Overuse Headache ('Rebound') | Daily or near-daily dull, diffuse headache present upon awakening, in a patient using acetaminophen, NSAIDs, triptans, or combination analgesics (Excedrin, Fioricet) > 10–15 days per month for > 3 months. | Normal neurological exam; diffuse pericranial tenderness; vital signs normal. | Zero neuroimaging indicated if long-standing pattern and normal neurological exam. | Patient education: explain the paradox of analgesics causing headaches. Formulate a structured weaning plan off overused analgesics. Initiate preventive agent (Topiramate, Propranolol, or Amitriptyline) with PCP/neurology follow-up. |
Emergency Department Chief Complaints & Ambulatory Care Guide
The comprehensive EMRA-style emergency shift handbook for non-emergent and ambulatory presentations across all primary ED chief complaints: Abdominal Pain, Low-Risk Chest Pain, Shortness of Breath/Dyspnea, Dysphagia & Swallowing Complaints, Primary Headaches, Musculoskeletal Back & Extremity Pain, Benign Dizziness & Vertigo, Flank Pain & Dysuria, Dermatologic Rashes, Eye Redness & Vision Complaints, ENT & Sore Throat, Gynecologic Pelvic Pain & Bleeding, Scrotal Pain, Palpitations, Nausea & Vomiting, and Mild Altered Mental Status. Details discriminating history questions ('What to Ask'), targeted physical exam maneuvers ('What to Look For'), Choosing Wisely imaging rules, bedside symptom order sets, and safe ambulatory discharge scripts.
Resuscitation Quick Actions • First 2 Minutes
Abdominal Wall vs Visceral
Carnett's Test: Pain increased by tensing rectus = abdominal wall pain (no CT needed); pain decreased = visceral intra-abdominal pathology
Chest Pain Low-Risk HEART
HEART Score 0-3 with normal ECG and negative serial troponin has < 1.7% 30-day MACE; safe for outpatient primary care/cardiology follow-up
Dyspnea PERC Rule
If low clinical probability for PE and ALL 8 PERC criteria met, risk of PE is < 1.4%; zero D-dimer or CTA chest indicated
Dysphagia Secretion Test
Inability to swallow secretions/drooling = complete obstruction -> emergent endoscopy (< 6h); tolerating sips of water = urgent outpatient or elective workup
Migraine ED Cocktail
Ketorolac 15-30 mg IV + Metoclopramide 10 mg IV + Diphenhydramine 25 mg IV + Dexamethasone 10 mg IV (prevents 72-hour relapse); avoid opioids
Choosing Wisely Back Pain
Zero radiographs or MRI indicated for acute low back pain < 6 weeks in absence of red flags (no saddle anesthesia, incontinence, or fever)
Dizziness BPPV vs Stroke
Dix-Hallpike positional torsional nystagmus = BPPV (treat with Epley maneuver, no meds); HINTS exam normal head impulse with direction-changing nystagmus = cerebellar stroke
Red Eye Visual Acuity
Always measure visual acuity FIRST; normal acuity + reactive pupil + clear cornea = benign surface conjunctivitis (no urgent ophthalmology consult needed)
Bottom-Line Clinical Pearl
Over 70% of emergency department presentations across primary chief complaints represent benign, self-limiting, or ambulatory conditions. Clinical mastery requires ruling out 'can't-miss killers' while avoiding reflexive low-value diagnostic imaging (unneeded abdominal CTs, lumbar radiographs, head CTs for recurrent migraines, or neck CTs for simple pharyngitis). Safe ambulatory discharge requires a documented four-point safety check: normal repeat vitals, successful oral challenge, pain controlled on oral non-opioids, and an explicit, time-sensitive red-flag return script.
Abdominal pain accounts for 8–10% of all emergency department visits. While training emphasizes acute appendicitis, cholecystitis, bowel obstruction, and ruptured AAA, over 60% of ambulatory patients in Fast Track or Main ED have self-limited, non-emergent etiologies that do not require CT imaging or admission.
| Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Choosing Wisely/Diagnostic Testing | Bedside Treatment & Discharge Strategy |
|---|---|---|---|---|
| Viral Gastroenteritis | Nausea, vomiting, and diffuse crampy pain preceding or concurrent with watery non-bloody diarrhea. Sick contacts, day care exposure, food history. Absence of focal localized pain. | Soft, non-distended, diffuse mild tenderness without localized guarding or peritoneal signs; hyperactive borborygmi; normal skin turgor or mild dehydration. | Clinical diagnosis! Zero labs or CT scans indicated in young, healthy, non-toxic patients. Check electrolytes only if severe dehydration, inability to retain fluids, or elderly. | Ondansetron (Zofran) 4–8 mg ODT, wait 15–20 minutes, then oral rehydration challenge (5–10 mL sips of electrolyte solution every 5 minutes). Discharge on oral rehydration and bland diet once fluid challenge tolerated. |
| GERD & Peptic Gastritis | Burning or gnawing epigastric pain radiating retrosternally, worse 30–60 minutes postprandially or when lying flat, sour taste/water brash, relieved by antacids. History of heavy NSAID, aspirin, or alcohol intake. | Mild epigastric tenderness to deep palpation; abdomen otherwise completely soft, non-tender, non-distended; normal bowel sounds; no peritoneal signs. | Check ECG and troponin in patients > 40 years old or with cardiovascular risk factors (inferior wall MI frequently mimics dyspepsia!). Fecal occult blood or CBC if chronic bleeding suspected. | GI Cocktail trial: 30 mL aluminum/magnesium hydroxide (Maalox) + 10 mL 2% viscous lidocaine provides prompt relief (note: relief does NOT exclude cardiac ischemia!). Discharge on oral PPI (Pantoprazole 40 mg daily) with primary care follow-up for H. pylori screening. |
| Constipation & Fecal Impaction | Dull, crampy LLQ or lower abdominal aching, bloating, no bowel movement for several days or passing hard Bristol Type 1 pellets, straining, tenesmus. Paradoxical 'overflow' liquid diarrhea in elderly impaction. Medication review: opioids, iron, anticholinergics. | Firm, non-tender, tubular palpable stool mass in left lower quadrant (sigmoid colon); tympanitic or dull percussion; digital rectal exam (DRE) reveals hard, packed fecal vault in the rectal ampulla. | Clinical diagnosis. Abdominal plain film (KUB) only if severe distension or fecal impaction vs pseudo-obstruction (Ogilvie syndrome) is in question. Zero CT imaging needed for routine constipation. | Digital disimpaction if hard low fecal shelf is reachable. Bowel cleanout protocol: Polyethylene glycol (MiraLAX) 17–34 g daily, Bisacodyl (Dulcolax) 10 mg PO or 10 mg suppository, and/or mineral oil or tap water enema. Increase dietary fiber and hydration. |
| Biliary Colic (Uncomplicated Cholelithiasis) | Episodic, severe, steady RUQ or epigastric pain radiating to the right infrascapular region, typically triggered by fatty or greasy meals, lasting 30 minutes to 4–6 hours, then resolving completely. History of identical prior self-resolving attacks. | Mild RUQ tenderness without peritoneal signs; NEGATIVE Murphy's sign (no inspiratory arrest on deep palpation); patient is afebrile, non-toxic, and comfortable between spasms. | Right Upper Quadrant (RUQ) Ultrasound: demonstrates acoustic shadowing gallstones WITHOUT gallbladder wall thickening (> 3 mm), pericholecystic fluid, or sonographic Murphy's sign. Normal LFTs, total bilirubin, and serum lipase. | Analgesia with IV Ketorolac (Toradol) 15 mg (NSAIDs block prostaglandin-mediated gallbladder contractility and are clinically superior to opioids for biliary colic). Discharge with outpatient elective surgical consultation; clear return precautions for fever, jaundice, or pain > 6 hours. |
| Irritable Bowel Syndrome (IBS) | Chronic recurrent abdominal cramping/pain (Rome IV criteria: >= 1 day/week for past 3 months) related to defecation, change in stool frequency or appearance. Absence of alarm features: no nocturnal pain, rectal bleeding, involuntary weight loss, or family history of IBD/colon cancer. | Mild diffuse lower abdominal discomfort, no peritoneal signs, normal bowel sounds, non-distended. | Basic metabolic panel and CBC normal. Zero CT imaging indicated in known IBS with typical baseline symptoms. | Reassurance, dicyclomine (Bentyl) 10–20 mg PO TID for acute spasm, low-FODMAP dietary counseling, PCP/gastroenterology outpatient referral. |
| Abdominal Wall Pain (Carnett's Sign) | Sharp, localized, superficial pain aggravated by movement, coughing, twisting, or lifting heavy objects. Patient can pinpoint the maximal tenderness with a single fingertip. | POSITIVE Carnett's Sign: Palpate the tender focal point while patient tenses abdominal wall (crosses arms and raises head/shoulders off gurney). If pain increases or remains identical, it is abdominal wall muscle strain or anterior cutaneous nerve entrapment. (If pain decreases, it is deep visceral pathology protected by the tensed rectus). | Zero laboratory or radiological imaging indicated. | Reassurance, topical lidocaine 5% patch, oral NSAIDs (ibuprofen/naproxen), heat/ice, avoidance of heavy lifting. |
| Non-Specific Abdominal Pain (NSAP) | Diffuse, vague, mild-to-moderate abdominal discomfort without clear localization, nausea without vomiting, normal bowel habits. Represents up to 40% of all ED abdominal pain visits! | Soft, non-distended, non-tender or mild diffuse tenderness without localized guarding or rebound; normal vital signs. | Urine pregnancy test in females of reproductive age (mandatory!), urinalysis. If exam remains benign and patient is young (< 50), observation and serial exams without advanced imaging are safe and evidence-based. | Symptomatic relief, clear liquid to bland diet advance, explicit return precautions. |
Once the lethal 6 (STEMI/NSTEMI, Pulmonary Embolism, Aortic Dissection, Tension Pneumothorax, Esophageal Rupture/Boerhaave, Cardiac Tamponade) are ruled out, over 60% of ED chest pain is benign musculoskeletal, gastrointestinal, or psychogenic.
| Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Diagnostic Testing & Risk Stratification | Bedside Treatment & Discharge Strategy |
|---|---|---|---|---|
| Costochondritis & Tietze Syndrome | Sharp, aching, localized anterior chest pain aggravated by deep inspiration (pleuritic), coughing, torso twisting, or reaching. Often preceded by heavy lifting, physical exercise, or persistent coughing. | Exquisite, reproducible point-tenderness upon direct palpation of the costochondral or chondrosternal junctions (typically 2nd to 5th ribs). Tietze syndrome displays visible localized fusiform swelling and erythema; costochondritis has NO swelling. | ECG is normal (or unchanged baseline). High-sensitivity troponin negative. Zero chest X-ray or CTA needed if classic reproduction on exam and low-risk clinical score. | Reassurance. Scheduled oral NSAIDs (Ibuprofen 600–800 mg TID or Naproxen 500 mg BID with food) for 7–10 days. Heat/ice therapy. Avoid provocative heavy lifting. |
| GERD & Esophageal Spasm | Substernal burning or squeezing pressure radiating to the back or neck, occurring after meals or when recumbent, sour acid regurgitation, dysphagia, relieved by antacids. Can mimic angina perfectly. | Completely normal cardiovascular and chest wall exam; no point tenderness; lungs clear; vitals normal. | ECG and high-sensitivity troponin mandatory to exclude cardiac ischemia (esophageal spasm can be relieved by nitroglycerin, mimicking angina!). | Trial of GI cocktail (antacid + viscous lidocaine) or oral PPI. Discharge on Pantoprazole 40 mg daily with primary care follow-up. |
| Musculoskeletal Chest Wall Strain | Aching, dull, or sore chest pain directly related to specific arm movements, sports, or coughing bouts. Patient can demonstrate which movement reproduces the pain. | Palpation reproduces pain over pectoralis major, intercostal muscles, or serratus anterior; pain elicited by resisted horizontal arm adduction or torso rotation. | Normal ECG. Zero biomarker or imaging testing needed in young, healthy patients. | Rest, ice/heat, oral acetaminophen/NSAIDs, stretching, avoidance of repetitive strain. |
| Anxiety/Panic Attack | Sudden onset chest tightness accompanied by intense fear, dyspnea, palpitations, perioral numbness, carpopedal spasm (hyperventilation respiratory alkalosis), trembling, diaphoresis. Prior history of panic attacks. | Tachycardia, tachypnea, but completely clear lungs; normal pulse oximetry; non-tender chest wall; no JVD or peripheral edema; agitated or hyperventilating. | Normal ECG (sinus tachycardia). Normal chest radiograph and negative high-sensitivity troponin. Arterial/venous blood gas reveals respiratory alkalosis (pH > 7.45, low pCO2). | Reassurance in a quiet room, coached slow diaphragmatic breathing (box breathing), oral hydroxyzine 25–50 mg or low-dose oral lorazepam (0.5–1 mg) if severe. Outpatient mental health referral. |
The HEART Score for Safe Ambulatory Discharge in Low-Risk Chest Pain
• History: Highly suspicious = 2, Moderately suspicious = 1, Slightly/Non-suspicious = 0.
• ECG: Significant ST depression/elevation = 2, Non-specific repolarization disturbance = 1, Normal = 0.
• Age: >= 65 = 2, 45–64 = 1, < 45 = 0.
• Risk Factors (HTN, hyperlipidemia, DM, smoking, obesity, family history CAD): >= 3 risk factors or CAD history = 2, 1–2 risk factors = 1, No risk factors = 0.
• Troponin: > 3x normal limit = 2, 1–3x normal limit = 1, Normal/negative = 0.
CLINICAL ACTION: A HEART Score of 0 to 3 with serial negative high-sensitivity troponins identifies patients with a < 1.7% risk of 30-day Major Adverse Cardiac Events (MACE). These patients can be safely discharged from the ED for outpatient primary care or cardiology follow-up without inpatient admission or urgent provocative stress testing.
Once acute respiratory failure, tension pneumothorax, pulmonary embolism, flash pulmonary edema, anaphylaxis, and foreign body aspiration are ruled out, a large subset of ambulatory patients present with non-life-threatening dyspnea driven by anxiety hyperventilation, acute viral tracheobronchitis, mild asthma exacerbations, or vocal cord dysfunction.
| Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Diagnostic Stewardship (Choosing Wisely) | Bedside Treatment & Discharge Plan |
|---|---|---|---|---|
| Hyperventilation Syndrome/Panic Episode | Sudden acute 'air hunger' or inability to take a deep enough breath, associated with overwhelming panic, perioral tingling, numbness in fingers/toes (paresthesias), and lightheadedness. Patient feels suffocated despite clear lungs. | Rapid, shallow thoracic breathing or frequent deep sighing; SpO2 99–100% on room air; lungs completely clear to auscultation bilaterally; carpopedal spasm (Trousseau sign equivalent due to transient hypocalcemia from acute respiratory alkalosis); no stridor or wheeze. | Pulse oximetry normal. Zero arterial blood gas or CTA chest required in low-risk young patients. Apply the PERC rule: if all 8 criteria negative and low clinical suspicion, zero D-dimer needed! | Reassurance and coached breathing: breathe slowly through pursed lips or into a cupped hand (box breathing: 4s in, 4s hold, 4s out, 4s hold). Never use paper bag rebreathing (risks hypoxia if missed organic disease). Oral hydroxyzine 25 mg PO if severe anxiety. |
| Acute Viral Tracheobronchitis | Persistent cough (1–3 weeks) that started with nasal congestion, sore throat, low-grade fever, and chest soreness behind the sternum during coughing. Mild subjective dyspnea during coughing paroxysms, but normal breathing at rest. | Normal respiratory rate (12–18); SpO2 >= 95% on room air; lung exam reveals coarse rhonchi or scattered wheezes that CLEAR or change character after vigorous coughing; zero focal rales/crackles, egophony, or dullness to percussion. | Zero chest radiograph indicated if vital signs normal (HR < 100, RR < 20, Temp < 38°C) and lung exam non-focal. Zero antibiotics indicated (90–95% viral; azithromycin provides zero clinical benefit and fosters resistance!). | Symptomatic relief: Honey/lemon lozenges, dextromethorphan or benzonatate (Tessalon Perles) 100–200 mg PO TID. Inhaled albuterol MDI 2 puffs q4–6h PRN if bronchospastic cough. Return precautions for persistent fever > 3 days or progressive dyspnea. |
| Mild Asthma/Reactive Airway Flare (Responders) | Known asthmatic with mild wheezing, chest tightness, or cough triggered by cold air, viral URI, or allergen exposure. Patient speaks in full sentences and is ambulatory. | Mild expiratory wheezing in lung bases; normal speech cadence; no accessory muscle use (no suprasternal retractions or abdominal breathing); SpO2 >= 95% on room air. Peak Expiratory Flow (PEF) > 70% of personal best. | Zero chest X-ray needed for routine mild asthma flare without fever, focal rales, or trauma. Zero bloodwork indicated. | Albuterol 2.5 mg + Ipratropium 0.5 mg nebulized x 1 (or 4–8 puffs albuterol MDI with spacer). Oral Dexamethasone 10–12 mg PO single dose (or Prednisone 40–50 mg daily x 5 days). Discharge once asymptomatic with clear lungs and PEF > 70–80% after 30–60 min observation. |
| Vocal Cord Dysfunction (Paradoxical Vocal Fold Motion) | Acute episodic shortness of breath and throat tightness, often in young female athletes or high-stress individuals; often misdiagnosed as refractory asthma unresponsive to bronchodilators. | INSPIRATORY wheeze or stridor heard loudest over the anterior neck/larynx (rather than chest); completely normal lung base auscultation; normal SpO2; symptoms abruptly improve during distraction, panting, or coughing. | Spirometry demonstrates blunted/flattened inspiratory flow-volume loop with normal expiratory curve. Chest X-ray completely normal. | Reassurance. Bronchodilators will NOT work and cause tremor. Speech therapy referral for respiratory retraining (panting, diaphragmatic breathing with tongue depressed). Reassure that airway will not close. |
| Post-Tussive Musculoskeletal Pain ('Pleurodynia') | Patient complains of 'difficulty breathing' because taking a deep breath causes sharp, severe chest wall pain, following days of severe paroxysmal coughing. | Direct point-tenderness over lower ribs or intercostal spaces; lungs clear to auscultation; shallow breathing due to splinting, but SpO2 normal. | Chest X-ray to rule out pneumothorax or rib fracture if severe focal trauma/osteoporosis; normal in simple muscle strain. | Scheduled oral NSAIDs (Naproxen 500 mg BID with food), topical lidocaine patches, cough suppressants (benzonatate). Emphasize incentive spirometry to prevent atelectasis. |
Choosing Wisely: The PERC Rule to Avoid Unnecessary D-Dimer & CTA Chest
In patients with dyspnea or pleuritic chest pain where clinical pre-test probability for Pulmonary Embolism is LOW (< 15%), apply the PERC Rule (Pulmonary Embolism Rule-out Criteria):
1. Age < 50 years
2. Heart rate < 100 bpm
3. SpO2 >= 95% on room air
4. No prior DVT or PE
5. No recent surgery or trauma requiring hospitalization within 4 weeks
6. No hemoptysis
7. No exogenous estrogen use (oral contraceptives, HRT)
8. No unilateral leg swelling
CLINICAL ACTION: If ALL 8 criteria are met in a low-risk patient, the post-test probability of PE is < 1.4% (below the test threshold). DO NOT ORDER A D-DIMER! (Ordering a D-dimer will yield false positives that trigger unnecessary radiation, contrast nephropathy, and cost from CTA scans).
Difficulty swallowing (dysphagia) or painful swallowing (odynophagia) generates urgent emergency consultations. The critical initial decision is ruling out complete airway-compromising or esophageal-perforating emergencies (food bolus impaction with inability to swallow secretions, button battery ingestion, epiglottitis, retropharyngeal abscess, Ludwig angina). Once these are ruled out, most ambulatory dysphagia is non-emergent.
| Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Choosing Wisely/Red Flag Screen | Bedside Treatment & Safe Disposition |
|---|---|---|---|---|
| Globus Pharyngeus ('Globus Hystericus') | Sensation of a 'lump in the throat', tightness, or foreign body sensation at the level of the cricoid cartilage. CRITICAL DISCRIMINATOR: The sensation is present between meals, is NOT accompanied by true difficulty swallowing food, and paradoxically IMPROVES during eating or drinking! Strongly exacerbated by anxiety, emotional stress, or frequent dry throat clearing. | Completely normal oropharyngeal exam; no pooling of secretions; normal neck palpation without mass or thyromegaly; normal speech (no muffled 'hot potato' voice); normal cranial nerves IX, X, XII. | Water Swallow Challenge: Patient comfortably swallows a full cup of water at the bedside without coughing, choking, or regurgitation. Zero CT soft tissue neck or barium swallow needed in acute ED visit. | Strong reassurance that there is no obstructive mass or choking hazard. Address underlying GERD (frequent silent trigger) with oral PPI (Pantoprazole 40 mg daily) and ENT/PCP outpatient referral. |
| Reflux Esophagitis & Distal Esophageal Spasm | Intermittent retrosternal food 'sticking' or burning ache behind the lower sternum, especially with dense solids, accompanied by acid regurgitation, water brash, or sour taste. Relieved by drinking water. | Normal vital signs; soft non-tender abdomen; no neck masses; normal oral cavity. | Check ECG/troponin if elderly or cardiac risk factors to rule out atypical angina. Zero emergency barium swallow or urgent CT needed. | Bedside GI cocktail (antacid + viscous lidocaine) trial. Discharge on oral PPI (Omeprazole 40 mg PO daily) and schedule outpatient elective EGD to evaluate for peptic stricture or Barrett's. |
| Pill-Induced Esophagitis ('Pill Ulcer') | Sudden onset severe, localized retrosternal chest/swallowing pain developing hours after swallowing a pill without water or immediately before lying down to sleep. Offending agents: Doxycycline, Tetracycline, Clindamycin, Potassium chloride, Iron, Aspirin/NSAIDs, Alendronate. | Normal vital signs, no neck swelling, lungs clear, no subcutaneous crepitus (ruling out Boerhaave rupture). Tolerates sips of cold water, though painful. | Zero chest CT or plain films needed if no vomiting, no subcutaneous emphysema, and patient is non-toxic. Zero emergency endoscopy needed unless unable to stay hydrated. | Discontinue or substitute the offending pill! Prescribe oral sucralfate suspension (1 g PO QID 1 hour before meals and at bedtime) + oral PPI (Pantoprazole 40 mg daily). Educate patient: always take pills with a full 8 oz glass of water and remain upright for at least 30 minutes. |
| Mild Aphthous Stomatitis & Herpangina | Severe pain when swallowing acidic liquids or spicy foods; shallow, painful ulcers on oral mucosa, tongue, or soft palate; mild low-grade fever; absence of airway distress. | Discrete shallow round ulcers with erythematous halos on buccal mucosa, soft palate, or anterior tonsillar pillars. Airway clear, tonsils non-obstructing, no trismus. | Zero bloodwork or CT imaging needed. Clinical diagnosis. | Topical oral analgesia: 'Magic Mouthwash' (equal parts viscous lidocaine 2%, diphenhydramine elixir, and aluminum/magnesium hydroxide) 5–10 mL swish and spit q4–6h PRN before meals. Oral hydration challenge. |
| Eosinophilic Esophagitis (EoE: Non-Obstructed) | Young adult (often male with personal/family history of asthma, atopy, or food allergies) reporting chronic, intermittent food 'hanging up' in lower chest, needing lots of water to wash down dry meats or breads. Currently able to swallow secretions. | Completely normal oropharyngeal and neck exam. Vitals normal. Able to swallow water smoothly. | If completely tolerating liquids and secretions, zero emergency imaging or immediate overnight endoscopy needed. | Outpatient Gastroenterology referral for elective outpatient EGD with esophageal biopsies (criteria: >= 15 eosinophils/HPF). Recommend trial of high-dose oral PPI (omeprazole 40 mg BID) and dietary elimination. |
The Dysphagia Red Flag Screen: Can They Swallow Saliva?
Whenever a patient presents with acute dysphagia, evaluate these three non-negotiable questions:
1. Can the patient swallow their own secretions? If DROOLING or spitting into a cup, this is COMPLETE ESOPHAGEAL OBSTRUCTION -> STAT GI consult for emergent endoscopy within 2 to 6 hours!
2. Is there stridor, muffled 'hot potato' voice, trismus, or neck crepitus? If YES, suspect Epiglottitis, Peritonsillar Abscess, Retropharyngeal Abscess, Ludwig Angina, or Boerhaave perforation -> STAT airway preparation and CT soft tissue neck!
3. Was a button battery or sharp foreign body swallowed? If YES -> Immediate emergency endoscopy (button batteries cause transmural liquefactive necrosis and aortic fistula within 2 hours!).
If the patient easily swallows a sip of water without choking, airway and complete obstruction are ruled out!
The primary emergency responsibility in headache is ruling out secondary catastrophic causes (subarachnoid hemorrhage, meningitis, venous sinus thrombosis, temporal arteritis, acute angle-closure glaucoma). Over 90% of headache visits represent primary benign headaches that require non-opioid abortive therapy and avoidance of low-value radiation.
Musculoskeletal complaints (back strain, ankle sprains, shoulder tendonitis, knee effusions) represent up to 25% of all emergency volume. The mandate in the ED is ruling out necrotizing soft tissue infection, compartment syndrome, acute septic arthritis, open fracture, and cauda equina syndrome. In their absence, management is non-opioid multimodal analgesia, functional splinting, and application of clinical decision rules.
| Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Choosing Wisely/Decision Rules | Bedside Treatment & Functional Care |
|---|---|---|---|---|
| Mechanical Low Back Pain & Sciatica | Dull, aching paraspinal lumbar pain following lifting, bending, or twisting; radiates to buttock or posterior thigh; improves lying down. Screen: normal bladder control, no saddle numbness, no fever, no IVDU, no cancer history. | Paraspinal muscle spasm; 5/5 motor strength (L4 dorsiflexion, L5 great toe extension, S1 plantarflexion); normal sensation; patellar and Achilles reflexes symmetric; negative straight leg raise. | Zero plain radiographs or MRI indicated for uncomplicated acute back pain < 6 weeks! (Radiographs expose to 75 CXR equivalents of radiation without altering management). | Multimodal non-opioid analgesia: Naproxen 500 mg PO BID + Acetaminophen 1000 mg PO TID + short-term muscle relaxant (Cyclobenzaprine 5 mg PO TID x 3–5 days). Avoid strict bed rest (maintain active walking!). Outpatient physical therapy. |
| Acute Ankle Inversion Sprain | Sudden inversion mechanism while stepping off curb or playing sports; 'pop' felt; acute lateral ankle pain and swelling. | Edema and ecchymosis over anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). Palpate the posterior edge of the lateral malleolus, medial malleolus, base of the 5th metatarsal, and navicular bone. | Apply Ottawa Ankle Rules: Ankle X-rays ONLY needed if bone tenderness at posterior 6 cm of lateral or medial malleolus OR inability to bear weight (take 4 steps) both immediately and in the ED. Foot series if tenderness at 5th metatarsal base or navicular. | PEACE & LOVE protocol: Protect, Elevate, Avoid anti-inflammatory ice in first 24h, Compress (lace-up ankle brace or Aircast), Educate. Early protected weight bearing as tolerated; crutches for 24–48h if severe limp. Follow up in 7–10 days. |
| Acute Subacromial Bursitis/Rotator Cuff Tendonitis | Anterior/lateral shoulder aching aggravated by overhead reaching, throwing, or sleeping on the affected side; gradual onset without acute fall or traumatic dislocation. | Positive Neer and Hawkins impingement signs; normal active and passive range of motion (passively intact rules out frozen shoulder); no gross deformity; neurovascular intact. | Zero MRI in the ED. Shoulder plain radiographs only if acute trauma or suspect calcific tendonitis. | Oral NSAIDs (Meloxicam 15 mg daily or Ibuprofen 600 mg TID with food), pendulum/range-of-motion exercises, sling for comfort ONLY (limit to < 24–48h to prevent adhesive capsulitis), outpatient PT referral. |
| Acute Gouty Arthritis (Uncomplicated) | Sudden, excruciating, nocturnal monoarticular joint pain, swelling, and redness (classic 1st MTP joint = podagra, or ankle/knee). Precipitants: red meat, alcohol binge, thiazide diuretics. | Erythematous, hot, swollen joint; exquisite tenderness to light touch (even a bedsheet causes severe pain). Afebrile, no overlying open puncture wound. | Arthrocentesis indicated on FIRST presentation or if Septic Arthritis cannot be excluded (synovial fluid shows negatively birefringent needle-shaped monosodium urate crystals under polarized light; WBC < 50,000; Gram stain negative). | First-line: Indomethacin 50 mg PO TID or Naproxen 500 mg BID x 5 days OR Colchicine 1.2 mg PO stat followed by 0.6 mg 1 hour later (if onset < 36h). Prednisone 40 mg daily x 5 days if renal failure or NSAID contraindicated. DO NOT initiate allopurinol during acute flare! |
Patients use 'dizziness' to describe four distinct sensations: Vertigo (spinning), Presyncope (feeling faint), Disequilibrium (imbalance walking), and Lightheadedness (anxiety/hyperventilation). The critical emergency task is distinguishing benign peripheral vestibular disorders from posterior circulation cerebellar/brainstem strokes.
| Sensation Type | Underlying Physiology | Key History Questions | Targeted Physical Exam | Bedside Management |
|---|---|---|---|---|
| Benign Paroxysmal Positional Vertigo (BPPV) | Otoconial canalithiasis in posterior semicircular canal. | Brief spinning episodes (< 60 seconds) triggered ONLY by changing head position (rolling over in bed, looking up at a shelf, lying down). No hearing loss, no tinnitus. | Dix-Hallpike Test: Elicits torsional upbeating nystagmus toward the lower ear with a 2–10 second latency, lasting < 60 seconds and fatiguing with repetition. | Epley Maneuver (Canalith Repositioning): Completely cures > 80% of patients at the bedside! Medications (meclizine, benzos) are INEFFECTIVE for BPPV and should not be prescribed. |
| Vestibular Neuritis | Viral inflammation of vestibular nerve (CN VIII). | Continuous, severe spinning vertigo lasting days, nausea, severe vomiting, gait unsteadiness. Often preceded by viral URI. NO hearing loss. | Spontaneous horizontal-torsional unidirectional nystagmus (fast phase beats away from affected ear; suppressed by visual fixation). HINTS exam: Positive (abnormal) Head Impulse Test (corrective saccade present confirms peripheral vestibular nerve lesion). | Short-term vestibular suppressants (Meclizine 25 mg PO q8h or Ondansetron 4 mg IV) for 24–48 hours ONLY (prolonged use delays central brainstem compensation). Oral hydration challenge. |
| Orthostatic Hypotension | Cerebral hypoperfusion upon standing. | Feeling faint, lightheaded, or 'graying out' specifically when rising from sitting or supine position. Dehydration, vomiting, poor oral intake, antihypertensive or diuretic medication changes. | Orthostatic Vital Signs: Document blood pressure and heart rate lying flat, then standing at 1 and 3 minutes. Positive if SBP drops >= 20 mmHg, DBP drops >= 10 mmHg, or HR increases >= 30 bpm. | IV or oral fluid rehydration. Review and hold offending medications (diuretics, beta-blockers, ACE inhibitors, alpha-blockers like tamsulosin). Patient education: rise slowly in stages. |
Urinary tract symptoms range from benign uncomplicated lower cystitis to life-threatening obstructive pyelonephritis, infected nephrolithiasis, or ruptured AAA. For stable ambulatory patients, rational urinalysis interpretation and radiation stewardship are essential.
| Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Diagnostic Stewardship (Choosing Wisely) | Bedside Treatment & Discharge Orders |
|---|---|---|---|---|
| Uncomplicated Lower Cystitis | Acute dysuria, frequency, urgency, suprapubic heaviness; absence of fever, chills, nausea, flank pain, or vaginal discharge. Premenopausal, non-pregnant female without urinary tract anomalies. | Mild suprapubic tenderness to palpation; completely NEGATIVE costovertebral angle (CVA) tenderness; afebrile; normal vital signs. | Point-of-care urinalysis: positive leukocyte esterase and/or nitrites. Zero urine culture needed in simple, classic first-time presentations! Zero renal ultrasound or CT scanning indicated. | First-line oral empiric antibiotics: Nitrofurantoin (Macrobid) 100 mg PO BID x 5 days OR TMP-SMX DS 1 tab PO BID x 3 days (if local resistance < 20%) OR Fosfomycin 3 g PO single dose. Urinary analgesic: Phenazopyridine (Pyridium) 200 mg PO TID x 2 days max (warn patient of orange urine discoloration). |
| Uncomplicated Ureteral Colic (Nephrolithiasis) | Sudden, severe, paroxysmal, colicky flank pain radiating to groin, testicle, or labia; hematuria; patient writhing on gurney unable to find comfortable position. Absence of fever or chills. | Mild flank tenderness without peritoneal signs; non-distended abdomen; testicular/pelvic exam normal; afebrile. | Urinalysis: microscopic or gross hematuria in > 85%. Low-dose non-contrast CT abdomen/pelvis (stone protocol) OR Renal Ultrasound (hydronephrosis check). If known recurrent stone former with identical symptoms and no fever, ultrasound or clinical management avoids repetitive radiation! | IV Ketorolac 15 mg (superior to opioids for ureteral smooth muscle spasm) + IV Ondansetron 4 mg + IV fluids. Medical expulsive therapy for distal stones 5–10 mm: Tamsulosin (Flomax) 0.4 mg PO daily. Discharge with urine strainer and outpatient Urology follow-up in 1–2 weeks. |
| Musculoskeletal Flank Strain | Aching flank or lower back pain aggravated by torso twisting, bending, or physical labor; constant ache; NO radiation to groin; NO dysuria or hematuria. | Focal tenderness over quadratus lumborum or erector spinae muscles; punch CVA percussion does not elicit internal visceral pain; normal vitals. | Urinalysis: completely normal (zero leukocytes, zero nitrites, zero blood). Zero imaging needed. | Reassurance, oral NSAIDs, warm compresses, stretching, avoidance of repetitive heavy lifting. |
Most dermatologic visits in the ED can be managed safely in Fast Track. The primary emergency physician responsibility is rapidly excluding life-threatening dermatologic emergencies: Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), DRESS syndrome, Necrotizing Fasciitis, Meningococcemia, Staphylococcal Scalded Skin Syndrome (SSSS), and Anaphylactic Urticaria.
| Dermatologic Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Red Flag Screen (Rule Outs) | Bedside Treatment & Topical Regimens |
|---|---|---|---|---|
| Contact Dermatitis (Poison Ivy/Rhus Dermatitis) | Severe pruritus developing 24–72 hours after outdoor hiking, yard work, or exposure to cosmetics/nickel. Linear streaks where plant brushed skin. | Linear vesicular plaques with erythema, edema, and weeping papules/vesicles; classic distribution on extremities or face; NO mucosal involvement. | Zero fever; mucosal surfaces (eyes, mouth, genitalia) completely spared; negative Nikolsky sign. | High-potency topical corticosteroid (Clobetasol 0.05% cream or Triamcinolone 0.1% cream) BID for localized lesions. If widespread (> 20% BSA or face/genitals), prescribe a 14–21 day oral Prednisone taper (40–60 mg starting dose; tapering too fast < 10 days causes rebound flare!). Calamine lotion and oral Cetirizine 10 mg daily for itching. |
| Pityriasis Rosea | Appearance of a single large initial oval plaque ('herald patch') followed 1–2 weeks later by widespread smaller itchy oval salmon-colored lesions on torso. | Multiple oval erythematous plaques with a fine collarette of scale along the inner border, oriented along skin cleavage lines ('Christmas tree' distribution on back). | Normal vital signs; oral mucosa completely clear; palmar and plantar surfaces spared (rules out Secondary Syphilis! Order RPR if palm/sole lesions present). | Reassurance: self-limiting over 6–8 weeks. Oral antihistamines (cetirizine/hydroxyzine) for pruritus, topical hydrocortisone 2.5% for itchy plaques, sunlight exposure. |
| Tinea Corporis/Cruris/Pedis (Dermatophytosis) | Pruritic, slowly expanding ring-like rash in groin, body, or web spaces of feet. History of public gym use, wrestling, or moisture. | Annular erythematous plaque with central clearing and an elevated, scaly, active advancing border. | No warmth, no fluctuance, no systemic signs (rules out cellulitis). | Topical antifungal: Terbinafine 1% cream BID or Clotrimazole 1% cream BID for 2–4 weeks (continue 1 week after clinical clearance). AVOID combination steroid creams like Lotrisone (betamethasone/clotrimazole) which worsen fungal infections and cause skin atrophy! |
| Acute Urticaria (Hives: Isolated) | Sudden appearance of intensely pruritic raised welts following viral illness, food ingestion, or contact; individual wheals resolve and migrate within 24 hours. | Transient erythematous edematous wheals with central pallor; blanche with pressure; dermographism present. | CRITICAL SCREEN: Zero lip, tongue, or uvular swelling; zero stridor, hoarseness, wheezing, dyspnea, nausea, or hypotension (rules out Anaphylaxis!). | Second-generation H1 antihistamine: Cetirizine 10–20 mg PO daily (or Fexofenadine 180 mg PO daily) +/- H2 blocker (Famotidine 20 mg PO BID). Short course of oral Prednisone (40 mg x 3–5 days) if extensive. Avoid NSAIDs, hot showers, and tight clothing. |
| Herpes Zoster (Shingles: Uncomplicated Localized) | Burning, tingling, or lancinating dermatomal pain preceding grouped painful blister eruptions by 2–4 days; immunocompetent adult. | Grouped vesicles on an erythematous base strictly respecting the midline in a single unilateral dermatome (most commonly thoracic). | CRITICAL SCREEN: Examine the tip of the nose (Hutchinson's sign = nasociliary branch of CN V1 involvement -> urgent ophthalmology consult for Zoster Ophthalmicus!); examine external ear canal (Ramsay Hunt syndrome/CN VII involvement). | Oral antiviral initiated within 72 hours of rash onset: Valacyclovir 1000 mg PO TID x 7 days (or Acyclovir 800 mg 5x/day x 7 days). Analgesia with oral acetaminophen/NSAIDs or Gabapentin 300 mg TID for neuropathic pain. Keep vesicles covered until crusted to prevent transmission of varicella to non-immune contacts. |
The emergency physician's priority in acute eye complaints is to separate sight-threatening ocular emergencies (acute angle-closure glaucoma, endophthalmitis, central retinal artery occlusion, corneal ulcer, retinal detachment) from benign, self-limiting anterior segment conditions.
| Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Diagnostic Pearls & Rule Outs | Bedside Treatment & Eye Drop Regimens |
|---|---|---|---|---|
| Viral Conjunctivitis ('Pink Eye') | Acute gritty sensation, burning, redness starting in one eye and spreading to the other 24–48 hours later; watery/serous discharge (morning crusting without copious thick pus); recent viral URI or sick contact. | Normal visual acuity; diffuse palpebral and bulbar conjunctival injection; watery tearing; tender preauricular lymphadenopathy (classic pathognomonic hallmark!); cornea completely clear. | Fluorescein stain: completely negative for corneal epithelial defect or dendritic branching (rules out HSV keratitis). Normal intraocular pressure (IOP 10–21 mmHg). | Strict hygiene education: frequent hand washing, separate towels, change pillowcases (highly contagious for 10–14 days!). Artificial tears QID and cold compresses. Zero antibiotic drops needed (viral!). Follow up with PCP or optometrist in 7 days. |
| Bacterial Conjunctivitis (Uncomplicated) | Copious, thick, mucopurulent discharge with eyelids glued shut upon awakening; continuous reaccumulation of pus at the medial canthus throughout the day. | Normal visual acuity; conjunctival injection; purulent exudate in conjunctival fornix; cornea clear; reactive pupils. | If patient is a CONTACT LENS WEARER, assume Pseudomonas aeruginosa until proven otherwise (requires fluoroquinolone drops!). If severe hyperacute purulent discharge within hours, rule out Neisseria gonorrhoeae. | Non-contact lens wearers: Polymyxin B/Trimethoprim (Polytrim) ophthalmic solution 1–2 drops QID x 5–7 days OR Erythromycin 0.5% ophthalmic ointment QID. Contact lens wearers: Ciprofloxacin 0.3% or Ofloxacin 0.3% ophthalmic drops QID (must cover Pseudomonas; discontinue contact lenses until cleared). |
| Subconjunctival Hemorrhage | Sudden dramatic appearance of a bright red blood collection in the eye, noticed by looking in the mirror or pointed out by family; completely PAINLESS; no vision changes. Preceded by coughing, vomiting, sneezing, heavy straining, or rubbing. | Normal visual acuity; dense, sharply demarcated, bright red patch of blood under the transparent bulbar conjunctiva; remainder of eye clear; pupils reactive; normal extraocular movements. | Check blood pressure. Zero eye imaging or lab testing needed in spontaneous isolated presentations. Ensure no history of blunt ocular trauma or globe rupture (360-degree bullous hemorrhage suggests occult globe rupture). | Strong reassurance: completely benign and self-limiting! Resolves spontaneously like a bruise over 1–3 weeks (turns yellow/green). Artificial tears for mild foreign body sensation. |
| Hordeolum (Stye) & Chalazion | Painful, focal swelling on the eyelid margin (hordeolum/acute stye = acute staph infection of meibomian gland or eyelash follicle) or painless, firm chronic nodule (chalazion = sterile granulomatous lip inflammation). | Focal, tender, erythematous nodule at eyelid margin or within the tarsal plate; eyeball itself completely white and uninvolved; visual acuity normal. | Screen: zero proptosis, zero pain with eye movement, zero ophthalmoplegia (rules out Preseptal and Orbital Cellulitis!). | Warm compresses applied to eyelid for 10–15 minutes QID with gentle massage. Erythromycin ophthalmic ointment BID to eyelid margin. If chalazion persists > 4–6 weeks, refer to Ophthalmology for elective incision and curettage. |
Pharyngitis and ear pain are among the most common ambulatory visits. The emergency priority is ruling out deep neck space infections (peritonsillar abscess, retropharyngeal abscess, Ludwig angina, epiglottitis) and malignant otitis externa. In benign presentations, clinical decision rules prevent unnecessary antibiotic overuse.
| Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Diagnostic Rules (Centor Score) | Bedside Treatment & Rational Care |
|---|---|---|---|---|
| Group A Strep Pharyngitis vs. Viral URI | Sudden sore throat, painful swallowing, fever; absence of viral symptoms (NO cough, NO rhinorrhea, NO conjunctivitis, NO diarrhea). | Tonsillar erythema and exudates; tender anterior cervical lymphadenopathy; palatal petechiae; scarlatiniform sandpaper rash (Scarlet fever). | Modified Centor (McIsaac) Score: Fever > 38°C (+1), Tonsillar exudates (+1), Tender anterior cervical adenopathy (+1), Absence of cough (+1), Age 3–14 (+1), Age 15–44 (0), Age >= 45 (-1). Score 0–1: Zero testing, zero antibiotics. Score 2–3: Rapid Strep Antigen Test. Score >= 4: Rapid test or empiric treat. | If Strep positive: Penicillin V 500 mg PO BID x 10 days OR Amoxicillin 500 mg PO BID (or 1000 mg daily) x 10 days OR single IM Benzathine Penicillin G 1.2 million units. If penicillin-allergic: Cephalexin 500 mg BID x 10 days or Azithromycin. Dexamethasone 10 mg PO single dose for rapid pain relief. |
| Acute Otitis Media (AOM) | Rapid onset of deep ear pain, feeling of fullness, decreased hearing, fever; preceded by viral URI. | Otoscopy: bulging, erythematous tympanic membrane (TM) with loss of normal bony landmarks and impaired TM mobility on pneumatic otoscopy; yellow purulent fluid behind TM. | Clinical diagnosis. Zero CT scanning needed unless post-auricular erythema and tenderness indicating Acute Mastoiditis! | First-line: Amoxicillin 875 mg PO BID x 10 days (or Amoxicillin-Clavulanate 875/125 mg PO BID if recent beta-lactam exposure or failure). Oral analgesics (ibuprofen/acetaminophen). |
| Acute Otitis Externa ('Swimmer's Ear') | Rapid ear pain, itching, fullness, yellowish ear drainage; recent swimming or cotton swab trauma. | Exquisite pain elicited by pulling the pinna or pushing the tragus (TUG TEST POSITIVE!); external auditory canal is edematous, erythematous, with purulent debris; TM intact. | Ensure patient is not diabetic or immunocompromised (must rule out Necrotizing/Malignant Otitis Externa with cranial nerve palsies, which requires CT temporal bone and IV ciprofloxacin!). | Topical antibiotic eardrops (NOT systemic antibiotics!): Ciprofloxacin/Dexamethasone (Ciprodex) 4 drops BID x 7 days OR Neomycin/Polymyxin B/Hydrocortisone (Cortisporin) 4 drops TID x 7 days (avoid Cortisporin if TM ruptured or perforated due to neomycin ototoxicity!). Ear wick insertion if canal severely swollen. |
| Cerumen Impaction | Gradual conductive hearing loss, ear fullness, mild discomfort, tinnitus, itchiness after cotton swab use. | Otoscopy reveals dark yellow, brown, or black wax completely occluding the external auditory canal; TM not visualized. | Examine canal to ensure no foreign body or perforation. | Warm water canal irrigation: instill docusate sodium (Colace) liquid or carbamide peroxide (Debrox) into ear canal for 15 minutes to soften wax, then gently irrigate with warm saline (body temperature to prevent caloric nystagmus and vertigo!) using an angiocatheter without needle. |
In any female of reproductive age presenting with lower abdominal or pelvic pain and vaginal bleeding, Ectopic Pregnancy is the non-negotiable rule out. Once pregnancy is definitively excluded by a negative urine/serum hCG, the clinician evaluates for pelvic inflammatory disease, ruptured hemorrhagic cysts, and benign ambulatory conditions.
| Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Diagnostic Evaluation | Bedside Treatment & Safe Regimens |
|---|---|---|---|---|
| Primary Dysmenorrhea | Recurrent, crampy, midline suprapubic pain starting 1–2 days before or with the onset of menses, radiating to lower back and thighs, resolving within 48–72 hours; normal regular cycles. | Completely normal pelvic examination; soft abdomen with mild suprapubic discomfort; normal vital signs. | Urine pregnancy test NEGATIVE. Zero ultrasound or labs needed in classic adolescent or young adult presentation. | Scheduled oral NSAIDs initiated at onset of symptoms: Naproxen 500 mg PO starting dose then 250 mg q6–8h OR Ibuprofen 600–800 mg PO TID with meals (blocks endometrial prostaglandin F2-alpha production). Local heat wraps. Outpatient discussion of combined oral contraceptives. |
| Mittelschmerz (Mid-Cycle Ovulatory Pain) | Sudden, mild-to-moderate unilateral lower quadrant pain occurring precisely at mid-cycle (day 14 of a 28-day cycle) corresponding to follicular rupture; lasts hours to 1–2 days; resolves spontaneously. | Mild unilateral lower quadrant tenderness; soft non-distended abdomen; no guarding, no rebound; normal vital signs. | Urine pregnancy test NEGATIVE. Pelvic ultrasound (if performed) shows a small amount of physiological free fluid in the pouch of Douglas with normal ovaries. | Reassurance. Short course of oral NSAIDs. Track menstrual cycles on calendar. |
| Uncomplicated Vulvovaginitis | Vaginal itching, burning, altered discharge, dysuria, superficial dyspareunia; absence of fever, pelvic pain, or systemic toxicity. | Vulvar erythema and excoriations; speculum exam reveals discharge characteristics: Candida = thick white curd-like ('cottage cheese') discharge; BV = thin, homogeneous gray-white malodorous discharge; Trichomonas = frothy yellow-green discharge with cervical petechiae ('strawberry cervix'). | Wet mount microscopy, vaginal pH testing (pH < 4.5 in Candida; pH > 4.5 in BV/Trichomonas), whiff test, and nucleic acid amplification testing (NAAT) for trichomonas, gonorrhea, and chlamydia. | Candida: Fluconazole 150 mg PO single dose. Bacterial Vaginosis (BV): Metronidazole 500 mg PO BID x 7 days OR Metronidazole 0.75% vaginal gel 1 applicator daily x 5 days. Trichomoniasis: Metronidazole 500 mg PO BID x 7 days (treat sexual partners!). |
Acute scrotal pain is an immediate surgical emergency until Testicular Torsion (loss of cremasteric reflex, high-riding transverse lie, zero blood flow on Doppler US) is excluded. Once torsion, necrotizing fasciitis (Fournier gangrene), and incarcerated hernia are ruled out, ambulatory scrotal complaints can be managed safely.
| Condition | What to Ask (Key History) | What to Look For (Physical Exam) | Scrotal Ultrasound Findings | Bedside Treatment & Disposition |
|---|---|---|---|---|
| Acute Epididymitis/Epididymo-Orchitis | Gradual onset unilateral scrotal aching and swelling developing over days, accompanied by dysuria, frequency, fever, or urethral discharge. | Tender, swollen, indurated epididymis located posterior to the testicle; positive Prehn sign (elevation of scrotum relieves pain, though NOT reliable enough to exclude torsion!); cremasteric reflex INTACT. | Color Doppler Scrotal Ultrasound: demonstrates HYPERVASCULARITY and increased blood flow to the enlarged epididymis and testis, with normal intratesticular blood flow. | Age < 35 (Sexually Transmitted: Chlamydia/Gonorrhea): Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg PO BID x 10 days. Age > 35 or enteric coliforms: Levofloxacin 500 mg PO daily x 10 days. Scrotal elevation with athletic supporter, ice packs, NSAIDs, and Urology follow-up in 1–2 weeks. |
| Torsion of the Appendix Testis | Sudden onset unilateral testicular pain in young boys (ages 7–12); less severe than testicular torsion; patient is ambulatory. | Point-tenderness localized strictly to the upper pole of the testicle; pathognomonic 'BLUE DOT SIGN' visible through the thin scrotal skin (infarcted necrotic appendix testis); normal vertical lie; cremasteric reflex INTACT. | Color Doppler Ultrasound: Normal intratesticular blood flow, with a hyperechoic or avascular mass at the superior testicular pole. | Conservative management: Reassurance (benign, self-limiting necrosis that resorbs over 7–10 days), bed rest, scrotal support, oral NSAIDs. Zero surgery required. |
| Varicocele | Dull, dragging scrotal ache or heaviness, typically on the LEFT side, worsening with prolonged standing or heavy lifting, relieved by lying supine. | Palpable, soft, tortuous mass superior and posterior to the testis described as a 'BAG OF WORMS'; decompresses when patient is supine and engorges during Valsalva maneuver. | Ultrasound: multiple dilated, tortuous pampiniform plexus veins > 2–3 mm in diameter with retrograde venous flow during Valsalva. | Scrotal support, oral NSAIDs, avoidance of prolonged standing, elective outpatient Urology consultation (evaluate for fertility implications). |
Palpitations range from harmless premature beats to malignant ventricular arrhythmias. In hemodynamically stable patients with a normal 12-lead ECG, the vast majority of presentations are benign premature contractions, caffeine/dehydration-induced sinus tachycardia, or anxiety.
| Arrhythmia/Sensation | What to Ask (Key History) | 12-Lead ECG Findings | Diagnostic Stewardship (Labs & Testing) | Emergency Management & Outpatient Follow-up |
|---|---|---|---|---|
| Premature Ventricular/Atrial Complexes (PVCs & PACs) | Feeling like the heart 'skipped a beat' or a sudden strong 'thump' in the chest followed by a pause. Triggered by lack of sleep, stress, excess coffee, energy drinks, nicotine, or decongestants. | Isolated, premature, wide QRS complex (> 120 ms) with discordant T wave not preceded by P wave (PVC), or premature narrow QRS preceded by an abnormal P wave (PAC); underlying baseline rhythm is normal sinus. | Electrolytes (potassium, magnesium) and TSH. If ECG is otherwise normal (normal QTc, no delta waves, no Brugada pattern), zero telemetry admission required! | Reassurance that benign ectopic beats occur in virtually all healthy individuals. Lifestyle modification: eliminate caffeine, energy drinks, alcohol, and pseudoephedrine. Outpatient Holter monitor referral if highly symptomatic. |
| Sinus Tachycardia from Dehydration/Anxiety | Gradual onset fluttering or racing heart during illness, fever, emotional upset, or after prolonged heat exposure. Absence of chest pressure, diaphoresis, or syncope. | Sinus tachycardia: normal P waves preceding every narrow QRS, rate typically 100–130 bpm with beat-to-beat variability (rate fluctuates with respiration and calm). | Evaluate for underlying causes: CBC for anemia, urine dipstick for dehydration, temperature check for fever. Zero troponin or urgent echocardiogram needed in young asymptomatic patients. | Treat the underlying cause: 1–2 L IV balanced crystalloid bolus for dehydration, antipyretics (acetaminophen) for fever, or quiet room and reassurance for anxiety. Discharge once heart rate settles < 100 bpm. |
Acute gastroenteritis and foodborne illness account for millions of emergency visits. The clinician must rule out surgical abdomen (SBO, appendicitis), intracranial hypertension (morning projectile vomiting), and DKA. Once excluded, the core emergency strategy is protocolized antiemesis and oral rehydration.
| Clinical Stage | Bedside Assessment & Clinical Signs | Emergency Protocol Orders | Discharge Readiness Criteria |
|---|---|---|---|
| Active Nausea & Vomiting | Patient actively vomiting, dry heaving, unable to keep sips of water down. Dry mucous membranes, tachycardia, mild orthostasis. | Administer Ondansetron (Zofran) 4–8 mg ODT or IV immediately. (Alternative: Metoclopramide 10 mg IV or Prochlorperazine 10 mg IV). Place on NPO status for exactly 15 to 20 minutes to allow the 5-HT3 receptor blockade to take full effect. | Do NOT allow patient to chug large cups of water immediately after antiemetic (gastric distension triggers recurrent vomiting reflex!). |
| Protocolized Oral Rehydration Challenge | Following 20 minutes of antiemetic rest, begin bedside oral challenge with oral rehydration solution (Pedialyte, dilute Gatorade, or water). | Order: 5 to 10 mL (1–2 teaspoons or small sips) every 5 minutes for 30 minutes. If tolerated without nausea, advance to 30 mL (1 oz) every 15 minutes. | Patient must successfully tolerate at least 8 to 12 oz of fluid over 60 minutes without emesis. |
| Acute Diarrhea Management | Watery diarrhea accompanying gastroenteritis. Screen: NO gross blood, NO black tarry stool, NO high fevers, NO recent antibiotics (ruling out C. difficile or invasive bacterial enteritis). | Rehydration is primary therapy. Avoid antimotility agents (Loperamide/Imodium) if high fever or bloody diarrhea (risks toxic megacolon and HUS in Shiga-toxin E. coli). Bismuth subsalicylate (Pepto-Bismol) 30 mL PO q30–60 min PRN. | Prescribe oral ondansetron 4 mg ODT PRN for home nausea, BRAT diet (bananas, rice, applesauce, toast), and clear return instructions for dizziness, inability to hold fluids for 24h, or bloody stools. |
Emergency clinicians frequently assess patients presenting with mild confusion, baseline dementia, or uncomplicated alcohol intoxication. The essential duty is distinguishing life-threatening acute encephalopathy (hypoglycemia, occult head trauma/subdural, Wernicke encephalopathy, sepsis, carbon monoxide, intracranial hemorrhage) from benign baseline or intoxicated states.
| Assessment Domain | Clinical Criteria for Safe Medical Clearance | Red Flags Mandating Acute Workup (CT Brain/Labs) |
|---|---|---|
| Point-of-Care Glucose & Vital Signs | Capillary blood glucose 70–180 mg/dL. Temperature 36.0–38.0°C, HR < 100, RR 12–20, SpO2 >= 95% on room air. | Hypoglycemia (< 70 mg/dL), fever (> 38°C indicates meningitis/sepsis), hypoxia, hypothermia, or refractory tachycardia/hypertension. |
| Trauma & Neurological Screening | Absence of external head trauma (Battle sign, raccoon eyes, hemotympanum, scalp hematomas); pupils equal and reactive; symmetric facial movements; no focal limb weakness. | Any evidence of acute head injury (mandatory non-contrast head CT), focal cranial nerve deficit, asymmetric motor exam, or ataxia out of proportion to intoxication. |
| Clinical Sobriety & Ambulation Test | Patient is awake, alert, oriented to person, place, and time; speaks in clear, coherent sentences; understands that they are in the hospital; demonstrates steady, unassisted ambulation with a safe, stable gait. | Persistent stupor, inability to protect airway, progressive lethargy, recurrent vomiting, or severe ataxia preventing safe standing. |
| Social Safety & Support Plan | Discharged into the care of a sober, responsible adult companion or safe shelter environment with transportation secured. | Patient attempting to drive, homeless in freezing temperatures, suicidal ideation expressed, or lack of safe disposition. |
Medically and legally, an emergency discharge note for any chief complaint must demonstrate that the clinician actively ruled out surgical and life-threatening pathology and established a safe ambulatory trajectory.
The Four-Point Safe Discharge Checklist (Document on Every Shift)
1. Vital Signs Stability: Afebrile, heart rate < 100 bpm, respiratory rate 12–20, normal blood pressure, and normal pulse oximetry on room air.
2. Oral Hydration Challenge: Successfully tolerated at least 8 to 12 oz of water or oral rehydration solution in the ED without recurrent emesis or agonizing cramping.
3. Adequate Pain Control: Pain score reduced to mild/manageable baseline utilizing oral non-opioid medications.
4. Independent Ambulatory Safety: Patient demonstrated safe, steady, unassisted ambulation without ataxia, orthostatic dizziness, or syncope.
DOCUMENTATION SHIELD PHRASE: 'Patient evaluated, examined serially, and observed in the ED. Vital signs stable and afebrile. Tolerated oral fluids without nausea. Pain controlled on oral medications. Ambulating safely with normal gait. Can't-miss surgical and life-threatening emergencies (e.g., peritonitis, acute coronary syndrome, pulmonary embolism, stroke, cauda equina, acute surgical abdomen) were actively considered and ruled out based on clinical history, examination, and diagnostics. Clear, specific, verbal and written return precautions explained; patient expressed complete understanding and agreement with outpatient plan.'
Board & Shelf Drill 5 Questions • Untimed Tutor Mode
Test Your Emergency Department Chief Complaints & Ambulatory Care Guide Clinical Acumen
Directly launch an active-recall practice block from our 8,400+ validated COMLEX Level 1, 2-CE & 3 board question bank with complete explanations.
Related Emergency Protocols & Differentials
Related EM Protocol
Acute Abdominal Pain & Surgical Emergencies
Surgical abdomen, ruptured AAA, mesenteric ischemia, and SBO.
Open Protocol Related EM ProtocolAcute Coronary Syndromes & STEMI Equivalents
STEMI criteria, Wellens, de Winter, Sgarbossa, and troponin dynamics.
Open Protocol Related EM ProtocolAcute Severe Asthma & COPD Exacerbation
Status asthmaticus, BiPAP titration, bronchodilators, and magnesium.
Open Protocol Related EM ProtocolEsophageal Motility & Food Bolus Impaction
Schatzki ring, eosinophilic esophagitis, and endoscopy timelines.
Open Protocol Related EM ProtocolAcute Headache, SAH & Intracranial Crises
Thunderclap headache, Ottawa SAH rule, LP vs CTA, and CVST.
Open Protocol Related EM ProtocolAcute Low Back Pain & Sciatica
Red flag screening, cauda equina, Choosing Wisely, and multimodal analgesia.
Open Protocol Related EM ProtocolAcute Vertigo & HINTS Protocol
HINTS exam, Dix-Hallpike maneuver, BPPV, and cerebellar stroke.
Open Protocol