What are the appropriate steps to evaluate and manage right sided pain?

Evaluation and Management of Right-Sided Pain

For right-sided pain, immediately obtain an ECG within 10 minutes if cardiac etiology is suspected, and proceed directly to CT abdomen/pelvis with IV contrast for right upper or lower quadrant abdominal pain as the primary diagnostic imaging modality. 1, 2

Initial Triage and Life-Threatening Causes

Immediate Assessment Required

• Obtain ECG within 10 minutes if chest pain is present to exclude STEMI, regardless of setting 1
• Transport urgently to ED via EMS (not personal vehicle) if any life-threatening features are present 1

Red Flag Features Requiring Emergency Evaluation

• Cardiac: Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, new mitral regurgitation murmur suggest acute coronary syndrome 1
• Aortic dissection: Sudden "ripping" pain radiating to back, pulse differential between extremities (30% of cases), connective tissue disorder features 1
• Pulmonary embolism: Tachycardia plus dyspnea (>90% of patients), pleuritic pain with inspiration 1
• Pneumothorax: Unilateral absent breath sounds, dyspnea and pain with inspiration 1

Location-Specific Evaluation

Right Upper Quadrant Pain

• Ultrasonography is the initial imaging test of choice for right upper quadrant pain to evaluate for acute cholecystitis and biliary pathology 1
• Look for right upper quadrant tenderness and Murphy's sign on examination 1
• Consider gallbladder disease, hepatic pathology, or lower lobe pneumonia 1

Right Lower Quadrant Pain

• CT abdomen and pelvis with IV contrast is the primary imaging modality with 95% sensitivity and 94% specificity for appendicitis 2
• Do not rely on normal white blood cell count to exclude appendicitis—the "classic" presentation occurs in only 50% of patients 2
• CT identifies the cause in the majority of cases, with 41% of non-appendiceal diagnoses requiring hospitalization 2
• Ultrasound has significantly lower sensitivity (51.8%) and should be reserved for reproductive-age females when gynecologic pathology is the primary concern 2

Right-Sided Chest Pain

• Serial ECGs should be performed if initial ECG is nondiagnostic to detect evolving ischemic changes 1
• Measure cardiac troponin as soon as possible after presentation if acute coronary syndrome is suspected 1
• Sharp pain increasing with inspiration and lying supine suggests pericarditis rather than ischemic heart disease 1
• Positional chest pain is usually nonischemic (musculoskeletal) 1

Pain Management Algorithm

Step 1: First-Line Agents for Mild-to-Moderate Pain

• Acetaminophen or NSAIDs are first-line for symptomatic treatment 3
• Choose based on pain type and patient risk factors for NSAID complications (gastrointestinal, cardiovascular, renal) 3
• Ibuprofen should be avoided if aspirin allergy, anticipated surgery, bleeding disorder, or renal disease present 1

Step 2: Combination Therapy if Inadequate Response

• Acetaminophen/opioid combination for moderate pain not controlled by first-line agents 3
• Consider multimodal approach targeting separate pain pathways simultaneously 3, 4

Step 3: Severe Acute Pain

• Potent opioids are appropriate for severe acute pain 3
• Reserve opioids for severe pain that cannot be managed with other agents 4
• Implement "universal precautions" approach including abuse risk assessment when prescribing opioids 5

Step 4: Neuropathic Pain Component

If neuropathic features are present (burning, shooting, dermatomal distribution):

• Gabapentin starting at 300 mg at bedtime, titrating up to 900-3600 mg daily in divided doses 1, 6
• Pregabalin 75-300 mg every 12 hours as alternative 1
• Duloxetine 60 mg once daily (start with 30 mg for 1 week to reduce nausea) 1
• Secondary amine tricyclic antidepressants (nortriptyline or desipramine) if gabapentinoids insufficient 1

Critical Pitfalls to Avoid

• Never delay transfer to ED for troponin testing if acute coronary syndrome is suspected in office setting 1
• Never exclude appendicitis based on normal WBC alone—imaging is mandatory 2
• Never use nitroglycerin response as a diagnostic criterion for myocardial ischemia 1
• Inadequate dosing is a frequent cause of treatment failure—gabapentin requires at least 900 mg/day for efficacy 6
• Avoid premature discontinuation of medications before reaching therapeutic levels or adequate trial duration 6

Reassessment Protocol

• Reassess pain within 6 months if no improvement observed 1
• Consider change in treatment, referral to specialist, or both if management ineffective 1
• Develop and agree on pain management plan with patient including ongoing assessment 1