1. Pathology
   1. Visceral
      1. "crampy, dull, or achy
      2. stretching of unmyelinated fibers
      3. visceral pain to be felt in the midline,
         1. stimuli are sent to both sides of the spinal cord
      4. Visceral Pain Features
         1. Foregut
            1. Stomach, first/second parts of duodenum, liver, gall bladder, pancreas
            2. Epigastric
         2. Midgut
            1. Third/fourth parts of duodenum, jejunum, ileum, cecum, appendix, ascending colon, first two thirds of transverse colon
            2. Periumbilical
         3. Hindgut
            1. Last one third of transverse colon, descending colon, sigmoid, rectum, intraperitoneal GU organs
            2. Suprapubic
   2. Parietal
      1. irritation of myelinated fibers
         1. localized to the dermatome
   3. Refer
2. CLINICAL FEATURES
   1. Is this patient critically ill?
      1. Red flags
         1. extremes of age severe pain of rapid onset abnormal vital signs dehydration evidence of visceral involvement (e.g., pallor, diaphoresis, vomiting)
      2. Orthostatic tachycardia
         1. An increase in pulse rate of 30 beats/min after standing for 1 minute
         2. เจอก่อน orthostatic hypotension
         3. เสียน้ำประมาณ 20%
      3. History
         1. "PPQRSTT": provocative/palliative factors, quality, radiation, associated symptoms timing what the patient has taken for the pain
      4. Physical Exam
         1. Inspection
         2. Auscultation
            1. Decreased
            2. ileus, mesenteric infarct, narcotic use, +-peritonitis
            3. Incresed
            4. Bowel Ob
         3. Percussion
         4. Palpation
            1. the middle three fingers, and saving the painful area for last
            2. Voluntary guarding
            3. contraction of the abdominal musculature in anticipation of or in response to palpation
            4. แก้โดย flex their knees
            5. Rigidity
            6. involuntary guarding or reflex spasm of abdominal muscles
            7. Peritoneal sign
            8. Rebound tenderness
            9. Opioid analgesia
            10. not obscure abdominal findings, delay diagnosis, or lead to increased morbidity/mortality
   2. Does the patient have a constellation of symptoms that fit a known disease pattern?
      1. Topic
      2. Topic
   3. Are there special conditions (risk factors) that would make it difficult to identify the critical illness or known disease process?
3. Treatment
   1. Analgesia
      1. opioid analgesia
   2. Antiemetic
      1. ondansetron
         1. 4-8 mgiv
         2. maximum of 32 milligrams daily
         3. S/E headache
      2. Metroclopramide
         1. 10 mg iv
         2. slowly to minimize extrapyramidal side effects
         3. 25 to 50 milligrams of IV diphenhydramine is administered as prophylaxis against dystonia
   3. Antibiotic