Abdominal pain is the most common chief complaint among emergency department patients, yet firm diagnosis and etiology elude us in up to 40% of cases. While young patients do not escape the risk of misdiagnosis and bad outcome, diagnosis is particularly difficult in the elderly, and in that special patient population, up to a third will require surgical intervention, with its significant associated mortality. Still, many patients will be discharged with a diagnosis of nonspecific abdominal pain. In some of those patients, the disease process will progress, and they will not fare well; and in others, the diagnosis will be missed because of unusual presentations. This article addresses how properly to manage and discharge those patients, while at the same time limiting one’s liability exposure.

There is a common myth that emergency physicians are risk-takers and “adrenaline junkies.” That may be true for some in terms of outside pursuits, but it is certainly not true when it comes to the disposition of patients. Call it defensive medicine or simply wanting to avoid bad outcomes for patients placed in our care. The question is this: What amount of risk are we willing to accept in the evaluation of a patient with undifferentiated abdominal pain? Zero risk is unrealistic, and would be prohibitively expensive and often impossible to achieve. It is far easier to rule something in than to rule it out. Therefore, we must accept some risk for both our patients and ourselves and manage it appropriately.

The Work-Up

Abdominal pain is a high-risk complaint and requires a thorough and focused physical examination and history. And, while there are some things that all patients should get, such as a pregnancy test in all women of childbearing age, not every test is warranted. One may decide to forgo a pelvic exam, complete blood count (CBC), or CT scan, for example, depending upon the complaint. If the result of a test is not going to change your management, do not order the test. The reason is that if there is an abnormal result, it is much more difficult to explain (or defend) why it was not pursued than why an inappropriate test was not ordered in the first instance.

So order what you think is needed, forget what will not change management, and have good solid reasons for what you do and do not do. For example, an 11-year-old girl presents with acute onset RLQ pain that is 10/10 and sharp in nature. It is associated with nausea. All else in the review of systems is negative. The patient has not had this before. She recently started menstruating and is just finishing her cycle. She is very tender in the RLQ, but all other quadrants are soft, nontender, and nondistended. What do you order? The patient swears that she is not sexually active. Do you order a urinary chorionic gonadotropin (UCG) test? Do a pelvic exam and screen for sexually transmitted diseases? You are concerned about appendicitis; do you order a CT scan or ultrasound? What about a CBC?

You must get a UCG. There are many reasons why a sexually active girl may not wish to divulge this information, so do the test. It’s easy, and it can change management decisions. Will you do a pelvic exam? This could go either way, but your reasons should be clear. Will you get an ultrasound or a CT scan? There should probably be an imaging study done unless it is a clinically clear picture of appendicitis, and even then, the surgeons will likely insist upon it. What about a CBC? Will a low, high, or neutral number of white blood cells change management? If not, don’t order the test.

You can do all of the right things, but if you don’t document it properly, it may as well never have happened.

The Handoff

The patient has been in the ED now for a couple of hours. Her pain is down to a 6/10 after 2 mg of morphine, and her nausea was relieved with antiemetics. You ordered an abdominal ultrasound to avoid radiation exposure, but unfortunately the appendix could not be visualized (no significant findings other than right-sided ovarian cysts, good blood flow to the ovary, and a small amount of free fluid in the pelvis), so you order a CT study to evaluate for appendicitis. You relate the patient’s history and pertinent findings and tell the oncoming physician to look for the CT results.

As the oncoming physician, you have an obligation to do a quick check of the history, do a focused physical exam, and write your own note. This can be done quickly, but it must be done. This is a high-risk complaint at a high-risk time. There is almost always some information lost in the shuffle, yet you are still responsible for knowing all of it, so quickly glance at the chart. Make sure that all chief complaints are addressed. For example, was there a syncopal episode? Vaginal discharge or bleeding? Keep an open mind about the differential diagnosis and do a quick reevaluation. You do not want to make your risk of liability that of the lowest common denominator, and you do not want to make a mistake due to framing effect.

The Disposition

The CT study comes back negative for appendicitis and confirms the findings on ultrasound. The patient’s pain is now 2/10, and she feels hungry and wants to go home. There is not really a convincing explanation for the sudden 10/10 pain and the small amount of free fluid in the pelvis, but you have done a thorough work-up given the findings and the history, the patient looks well, and you want to discharge her. This point in the encounter is the time of highest risk, and you must do several things. First, reexamine the patient. A patient with abdominal pain should have serial exams, including an exam prior to discharge. Second, give strict precautions that include returning to the ED within a certain amount of time (say, 8 hours) if the pain is not gone or gets worse, if fever develops, or if the patient has nausea and vomiting. Third, ensure adequate and close follow-up. In this case, it may be an appointment with an ob.gyn. within the next few days or a week. Fourth, explain that you do not have a good answer for the abdominal pain, and emphasize that that is why precautions must be taken and follow-up appointments must be made and kept.

The Documentation

You can do all of the right things and give excellent patient/family education, but if you don’t document it properly, it may as well never have happened. Let’s look at this case. First, document why a pelvic exam was not done (denial of sexual activity, age, no history of vaginal bleeding or discharge, unilateral pain, etc.), that the risk of misdiagnosis that could result from not doing a pelvic exam was explained to the patient, and that there will be close follow-up with an ob.gyn. Second, document anything from sign-out that is needed, such as confirmation of history, focused exam findings, and the like. Third, always document when you have reevaluated the patient, and give the time and a brief description. This may be just quickly popping your head in the room and observing that the patient is laughing and eating. Most important in abdominal pain, document the time and exam findings of serial evaluations, particularly just prior to discharge. Fourth, document the precautions given to the family and that the family understands, especially with regard to when they should return for further evaluation. Fifth, document the follow-up time and that the family understands why this is important. Finally, it is especially important to document any red flags (such as a small amount of free fluid in the pelvis) and demonstrate that you thought about it, explained it to the patient/family, and gave strict precautions relating to it. This may sound burdensome, but it can be done quickly and does not require a dissertation, particularly if you have a good system for discharge instructions.

The Ultimate Judgment

You are likely to be sued in your career—at least once. However, you have a lot of control over how that case goes. Often a physician is brought in on a lawsuit because he or she was one of many people to see the patient, not because that physician did anything wrong. Get into the habit of thoughtful evaluation, careful handoffs, excellent documentation, and a thorough explanation to the patient/family of risks and the importance of vigilance. You cannot eliminate risk for your patients, but you can certainly go a long way toward ensuring better outcomes for them and minimal litigation risk for yourself.

Dr. Stankus is a senior emergency medicine resident at the University of New Mexico, a veteran member of the ACEP Medical-Legal Committee, and a frequent contributor to ACEP News.