Potential diagnoses | History | Clinical | Laboratory/imaging/ other testing |
Acute systemic illness |
Multiorgan failure | - Chronic pain, lung disease, or renal insufficiency
| - Fever, ↑ RR, ↑ HR, BP changes
- Nonfocal neurologic changes
- Pain is often severe with rapid organ failure
| - ↓ hemoglobin and platelets
- ↑ bilirubin, LDH, creatinine
- Signs of rhabdomyolysis
- Infiltrate on CXR
|
Hemolytic transfusion reaction (HTR) | - Recent transfusion (within 24 hours for acute HTR; up to one month for delayed HTR)
- History of alloimmunization
| - Jaundice, dark urine
- Fever, ↑ HR
| - ↓ hemoglobin and platelets
- ↑ bilirubin, LDH
- Positive Coombs (direct antiglobulin) test
- Hemoglobinuria
|
Headache |
Stroke | - Prior stroke or silent cerebral infarct
- History of ↑ transcranial Doppler velocities
| - Headache
- Focal or non-focal neurologic findings
| - Brain imaging helpful if positive but may initially be negative
- Presumptive treatment with simple transfusion is done while obtaining brain imaging if suspicion is high
|
Brain aneurysm | - Usually asymptomatic but may have headache, loss of visual acuity, or facial pain
| - Usually negative if unruptured but may have cranial neuropathies
| - Positive MRI or CT angiography
|
Meningitis* | - Fever, meningeal symptoms
| | |
Migraine | - Aura
- Typical migraine symptoms for that patient
| - May show focal or nonfocal findings
| - No diagnostic laboratory test
|
Chest pain |
Acute chest syndrome (ACS) or pneumonia* (indistinguishable) | - History of pulmonary disease, prior ACS, asthma, recent infection
| - ↑ RR, ↓ oxygen saturation
- Children: Fever, cough
- Adults: Afebrile, severe pain that may initially overshadow the pulmonary symptoms
| - ↓ hemoglobin
- Infiltrate on CXR helpful if present, but may initially be negative, and absence does not eliminate possibility of ACS
|
Pulmonary embolism | - History of DVT helpful if present but often absent
- Pregnancy, recent surgery, indwelling catheter, or other hypercoagulable state
| - ↑ RR, ↑ HR
- ↓ oxygen saturation
- Extremity pain/swelling
| - ↑ D-dimer
- Imaging decisions depend on pretest probability and D-dimer
- Chest imaging and/or extremity imaging may be appropriate
|
Pulmonary fat embolism | - History of pulmonary disease or recent surgery
- Severe extremity pain
| - ↓ oxygen saturation
- ↑ RR
- Nonfocal neurologic symptoms
- Patients may deteriorate rapidly and develop multi-organ failure
| - ↓ hemoglobin, platelets
- ↑ nucleated RBCs
- Infiltrate on CXR
- Diagnosed by bronchoscopy
|
Acute coronary syndrome | - History of cardiac disease, pulmonary hypertension, or ↑ QT interval
- Patients with SCD and severe vaso-occlusive pain are increasingly recognized to have acute myocardial ischemia without major vessel disease
| - Atypical chest pain
- Radiation to arm(s)
| - ↑ cardiac biomarkers
- Abnormal EKG
|
Rib infarct | | - Focal rib tenderness
- Pain on inspiration
- Splinting may cause hypoventilation
| - Negative CXR
- Positive bone imaging
|
Abdominal pain |
Splenic sequestration | - History of splenic or hepatic sequestration
- Infants with hemoglobin SS; adults with SCD variants
| - Variable abdominal pain, requires a high index of suspicion
- Hemodynamic instability, ↑ HR, ↑ BP
- Splenic enlargement (rapidly enlarging spleen needs to be closely monitored)
| - ↓ hemoglobin, ↓ platelet count
- ↑ reticulocyte count
|
Hepatic sequestration | - History of splenic or hepatic sequestration
- History of underlying hepatic disease
- May be exacerbated by hepatic iron overload, HCV infection, or other causes of liver dysfunction
| - Right upper quadrant pain and/or tenderness
- Hemodynamic instability, ↑ HR, ↑ BP
- Acute hepatomegaly, can progress to acute hepatic failure
| - ↓ hemoglobin
- ↑ PT, ↑ aPTT
- hyperbilirubinemia
|
Gallstones or cholecystitis* | | - Acute RUQ pain or tenderness
- Jaundice
- Nausea
| - ↑ bilirubin, ↑ transaminases
- ↑ WBC
- Positive RUQ ultrasound or other imaging
|
Renal infarct | | - Hematuria
- Back pain and/or flank or CVA tenderness
| - RBCs on urinalysis
- Variable ↑ in creatinine
- Acute papillary necrosis on renal imaging
|
Ectopic pregnancy | - Sexually active reproductive age female
| - Lower abdominal pain, especially after menses
- Abnormal uterine bleeding or discharge
- Nonspecific symptoms (urinary frequency, vaginal discharge)
- Abdominal and pelvic examinations are often unremarkable if the pregnancy has not ruptured
- Cervical motion tenderness, adnexal tenderness, or uterine tenderness are common with rupture
- An adnexal mass may be palpable
- Excessive pressure on the adnexa should be avoided because it may cause rupture
| - Positive pregnancy test
- Diagnosed by serial quantitative HCG testing and transvaginal ultrasound
|
Pelvic inflammatory disease | | - Lower abdominal pain, especially after menses
- Abnormal uterine bleeding or discharge
- Nonspecific symptoms (urinary frequency, vaginal discharge)
- Fever in severe cases
- Cervical motion tenderness, adnexal tenderness, or uterine tenderness are defining characteristics
- Purulent vaginal or endocervical discharge
| - Clinical diagnosis
- ↑ WBC may be present but is not highly sensitive or specific
- Additional testing includes pregnancy test, urinalysis, microscopy of vaginal discharge, testing for chlamydia, gonorrhea, HIV, and syphilis
- Imaging for selected cases to evaluate for complications such as tubo-ovarian abscess or to exclude ectopic pregnancy
|
Urinary tract infection or pyelonephritis* | - Urinary tract infection can precipitate an acute pain episode
| - Fever
- Suprapubic tenderness
- Children: May not report any symptoms
- Adults: May have urgency, frequency, dysuria, flank pain
| - Positive urinalysis and culture
|
Opioid-induced constipation | - Recent opioid use, typically within the previous 72 hours
- Lack of a consistent bowel regimen
| | |
Extremity or bone pain |
Acute synovitis or avascular necrosis (AVN) of a joint | - History of avascular necrosis
| - Hip pain
- Limp
- Limited range of motion
- Pain accompanied by joint swelling
| - Radiography is negative in early stages of AVN
- MRI may be needed to document findings
|
Dactylitis | - Infant or young child (rarely seen above the age of four years)
| - Pain with swelling and warmth of the fingers or toes
| |
Gout | - Older adults
- History of renal disease, hypertension, or gout
| - Joint pain in atypical areas such as phalanges, angles, elbows, wrists
- Pain accompanied by joint swelling
- Monoarticular joint pain may be accompanied by more diffuse pain from vaso-occlusion
| - Variably ↑ creatinine, urate
- Urate crystals in joint fluid
|
DVT | - Pregnancy, recent surgery, indwelling catheter, or other hypercoagulable state
| | - ↑ D-dimer
- Compression ultrasonography or other noninvasive testing
|
Osteomyelitis | - History of bone infarction, avascular necrosis, or gastroenteritis
| - Can present with generalized bone pain
- Pain accompanied by swelling, tenderness, warmth
- Variable joint involvement (can be multifocal)
| - Diagnosis often delayed; often confused with bone infarct (much less common)
- ↑ WBC
- Blood, bone, and joint aspirate cultures positive for salmonella, staphylococcus
- Imaging may show periosteal elevation and/or fluid collection
|
Generalized/diffuse pain |
Neuropathic pain | - History of chronic pain and ineffective opioids
| - Pain described as burning, shooting, or tingling
- Hyperalgesia to touch or temperature
| - No diagnostic laboratory tests
|
Opioid or steroid withdrawal | - Recent hospitalization for pain episode
- Sudden withdrawal of opioid or steroid without tapering
| - Pain may be severe
- Agitation, ↑ tremors
- Gastrointestinal symptoms
- Sweating
| - No diagnostic laboratory tests
- A common cause of readmission
- When withdrawal is expected, we prefer to use the Clinical Opiate Withdrawal Scale (COWS), an 11-item scale designed to be administered by a clinician
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