Case 2

Yes – as long as certain criteria are met.
Patients will frequently be discharged from the ED without a diagnosis.

The following criteria need to be meet to discharge a patient without a cause for their symptoms being found (these criteria hold true for many other presentations, not just abdominal pain).

1. Have you - through history, examinations and investigations - ruled out potentially serious or life-threatening causes for his pain?

• Not every serious diagnosis needs to have investigations to exclude it. For example in a 25 year old with nonspecific abdominal pain, you are unlikely to obtain a CT aorta for an AAA, as this is very rare at this age. But in a 65 year old, you are much more likely to.

2. Have you arranged follow-up for the patient.

• This may be with his GP for a review in a few days, or clinic follow-up.

3. Have you arranged any outpatient investigations that may be indicated?

• In this case, does he need an outpatient biliary tract or renal tract USS for stones? Remember, If you order an investigation, you are responsible for ensuring it happens and reviewing and acting on the results as necessary.

4. Is the patient comfortable? 

• One mistake doctors make is to give a patient a large dose of morphine and then discharge them as they are now comfortable, only for the pain to return once the morphine wears off. Patients without a diagnosis for their pain should be observed several hours post morphine prior to discharge.

5. Does the patient accept that there is currently no diagnosis for there pain, are happy with the follow-up arrangement and understands what to do if the pain returns?

• If you send a patient home who is either unhappy about the lack of diagnosis, is not happy without patient investigations or feels their pain has not been taken seriously, they will just represent to hospital.

6. Can the patient easily return to hospital ie. do they have a car or phone to call an ambulance? How far away from hospital are they? Do they have family support or do they live alone?

• If your patient is a distance from hospital, has no car or no phone, it may be safer to admit or keep them for a longer period.

(1)  He needs to be informed that we do not know why he has the pain but we have not found any sinister causes.

(2)  He needs advice on when to return, such as:

• If his pain worsens
• If he develops new symptoms such as vomiting or dizziness etc
• If he develops a fever

(3)  He needs to do the follow-up arrangements

• Either with his GP or that you have referred him for clinic follow-up
• What outpatient investigations have been ordered, and how he will find out the results (eg. via his GP, we will call him etc)