What labs and imaging should be ordered for a patient with a significant pain level but mild exam findings?

From the Guidelines

For a patient with significant pain but mild exam findings, I recommend starting with basic laboratory tests including complete blood count (CBC), comprehensive metabolic panel (CMP), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) to assess for inflammation or infection, and then proceeding with imaging studies based on the location of the pain, with ultrasonography as the initial imaging test of choice for right upper quadrant pain and computed tomography (CT) for right or left lower quadrant pain, as suggested by the American College of Radiology's Appropriateness Criteria 1.

When evaluating a patient with acute abdominal pain, it is essential to consider the location of the pain to determine the most appropriate imaging study.

• For patients presenting with right upper quadrant pain, ultrasonography is the initial imaging test of choice 1.
• For patients presenting with right or left lower quadrant pain, computed tomography (CT) is the recommended initial imaging study 1.
• Conventional radiography has limited diagnostic value in the assessment of most patients with abdominal pain and should not be the initial imaging test, except in select cases such as suspected bowel obstruction, perforated viscus, urinary tract calculi, or foreign bodies 1.

The patient's significant pain level despite mild exam findings warrants further investigation to rule out underlying pathology that may not be evident on physical examination alone.

• Additional targeted tests may be warranted based on clinical suspicion, including beta human chorionic gonadotropin testing in women of reproductive age 1.
• The choice of imaging study should be guided by the clinical presentation and the American College of Radiology's Appropriateness Criteria to minimize unnecessary testing and exposure to ionizing radiation.

In terms of disposition, the patient should be closely monitored and further evaluated based on the results of the laboratory tests and imaging studies.

• If the patient's condition worsens or if serious pathology is suspected, prompt referral to a specialist or admission to the hospital may be necessary.
• The patient's pain management should also be addressed, with consideration of multimodal therapy to optimize pain control and minimize the risk of adverse effects.

From the Research

Labs and Imaging

• For a patient with a significant pain level but mild exam findings, it is essential to consider various diagnostic approaches to determine the underlying cause of pain 2.
• The choice of labs and imaging depends on the clinical suspicion and potential diagnoses, such as acute appendicitis, pulmonary embolism, or renal colic 3, 4.
• Computed Tomography (CT) scan with intravenous (IV) contrast may be considered for diagnosing acute appendicitis, while ultrasonography is the initial modality of choice 3, 4.
• Magnetic Resonance Imaging (MRI) can be an alternative to CT scan, especially during pregnancy or lactation, when the use of contrast media is a concern 4.

Disposition

• The patient's disposition depends on the diagnosis and severity of the condition.
• If the patient is diagnosed with a life-threatening condition, such as acute compartment syndrome, bowel ischemia, or necrotizing fasciitis, immediate surgical intervention or transfer to a higher-level care facility may be necessary 2.
• For patients with unexplained pain, close monitoring and repeated evaluations are crucial to prevent misdiagnosis or delayed treatment 2.
• Patient satisfaction with pain management is inversely correlated with pain intensity, and healthcare providers should consider the patient's preferences and concerns when developing a treatment plan 5.