Running Head: ABDOMEN
Abdominal Pain
1767-20180731-005
November 11, 2018
Abdominal Pain
Subjective
CC: " Abdominal pain”
HPI: Patient is a 30 year old female complaining of abdominal pain and indigestion. The dull,
constant pain is located in the upper right quadrant of her abdomen. It started four days ago and
is occasionally also in her right shoulder blade. Nausea accompanies the pain. Eating worsens the
pain, making her feel excess gas and bloating. Rolaids normally lessens the pain but did not
improve her pain in the last incident. One a scale of 10, she rates the pain as an 8. No c/o blurred
vision dizziness, any chest pains, n/v. last time he saw an eye doctor was sometime last year for a
pink eye. denies use of contacts lenses or any eye wear. Denise any changes in vision
PMH: Denies
ETOH use: Denies
Social History: Pt is a single college student. She lives in an on-campus apartment that she shares
with 3 other girls. Her major is Horticulture and she enjoys playing the cello. She does not have a
Surgical History: Married and has 2 children.
Family History: Her brother had his gall bladder removed 2 years ago. Mother died of
alzheimers, father of heart attack.
Psychiatric: Denies
Allergies: NKDA
ROS:
Abdominal Pain
GEN: Denies pain, fever, or weight changes. C/o feeling fatigue at times mostly in the afternoon.
HEENT: Denies HA, dizziness, sore throat, changes in vision or hearing. NECK: Denies neck
pain, hoarseness, or difficulty swallowing. CHEST: Denis cough, shortness of breath with
exertion or at rest. Denies pain with inspiration or expiration. CV: denies any chest pains or
palpitations. GI: Denies nausea/vomiting, C/O abdominal pain. Denies chronic diarrhea. Denies
history of jaundice, gall bladder, or liver disease. GU: Denies dysuria, incontinence, or changes
in voiding pattern. MUSC: No limitation in extremities NEURO: Denis headache, syncope,
dizziness, muscle weakness or ataxia. PV: Denies any extremity swelling or changes in
temperature. PSYC: Pt reports she feels depressed.
Current medications:
None
Source of information: Patient
Objective
Vital Signs: Wt.: 140Ibs, T: 98F, HR: 97, RR: 16, SPO2: 95% RA, BP: 120/60.
Physical Exam: Pt is awake, alert, and cooperative. Clothing is well kept and appropriate for
season. He is oriented to person, place, and time and answers all questions appropriately.
Appears stated age, appears to be healthy, and does not appear to be in any acute distress.
PERRLA intact. Skin: Warm, dry, supple, no bruises, rashes, or suspicious nevi to exposed skin.
Smooth and well-manicured without clubbing or cyanosis. Capillary refill to finger <3 seconds.
Scalp pink and moist, no pain on palpation, no signs of trauma on scalp. No sinus tenderness,
and no palpable lymph node enlargement or tenderness. Neck supple; thyroid isthmus palpable,
lobes not felt. Trachea midline. Membranes pink and moist. Uvula is midline, tonsils at pillars,
Abdominal Pain
no redness or exudates. Good dentition noted. Respirations 20 breaths/min, breath sounds
vesicular, no rhonchi, wheezes, or crackles present. Lungs resonant. Thorax is symmetric, and
the diaphragms descend 4 cm bilaterally. No limitation in ROM or mobility.
Assessment
No surgical scars, no distention. Normal active bowel sounds in all four quadrants. No
bruits heard in abdominal aorta, renal arteries, or iliac arteries. Discomfort was felt on light and
deep palpitation of the right upper quadrant. Liver and spleen are not enlarged. She had no
rebound tenderness or guarding.
Diagnosis: Abdominal pain
Differential Diagnoses: gall stone, Pancreatitis gastritis, peptic ulcer disease
Plan
1. Abstain ultrasound of abdomen
2. Obtain EKG
3. Refer to GI per Ultrasound results
4. Medicate for pain with Tylenol 650 mg PO Q4 PRN (per pt it works well for her)
5. Lab work (CBC. CMP, U/A)
6. F/u in 3 months
Pathophysiology
Abdominal Pain
Abdominal pain comes from the abdominal viscera, which are innervated by autonomic
nerve fibers and respond mainly to the sensations of distention and muscular contraction not to
cutting, tearing, or local irritation. Visceral pain is typically vague, dull, and nauseating. It is
poorly localized and tends to be referred to areas corresponding to the embryonic origin of the
affected structure. Foregut structures (stomach, duodenum, liver, and pancreas) cause upper
abdominal pain. Midgut structures (small bowel, proximal colon, and appendix) cause
periumbilical pain. (Parswa. Ansari, 2018), Hindgut structures (distal colon and GI tract) cause
lower abdominal pain.
Pharmacology
Depending on the severity of the patient condition. The provider will most likely start a
treatment plan that involves dietary measures including fiber supplementation, low fermentable
oligosaccharides, disaccharides, monosaccharides and polyols diet, and pharmacological
approaches such as antispasmodics, peppermint oil, antidepressants (tricyclic agents, selective
serotonin reuptake inhibitors), 5-HT3 receptor antagonists (alosetron, ondansetron, ramosetron),
non-absorbed antibiotic (rifaximin), secretagogues (lubiprostone, linaclotide). (Camilleri. M,
2018). Potential new approaches may be based on recent insights on the mucosal expression of
genes, and microRNA and epigenetic markers in human biopsies and in animal models of
visceral hypersensitivity.
Critical Thinking / Clinical Decision Making
Because of the client's age, I focused on the assessment and most importantly the history.
She had no previous history of GI problems and no family related history as well. I then focused
Abdominal Pain
on possible things she may have ingested to roll out food poisoning. Because of the duration of
her symptoms, that was ruled out as well. I then decided it was appropriate to do lab and exam
studies on this patient before further treatment plans can be implemented. An abdominal
ultrasound was needed and depending on the results the patient was to be referred to GI.
Ethical and or Cultural Concerns
With this client, because of her age, I was unsure of how she would comply with her
treatment plan. She had previously stated she had no money and was concern about how much
her insurance would cover if we referred her to GI and further workup was needed. Altering a
patient treatment plan because of their insurance coverage just didn’t seem ethical in this
situation or any for that matter. The decision was to be left to the patient.
Barriers to Care
I faced the same issue with this client as I have with several clients who are young. With
this particular client, I was concerned about her commitment to her treatment plan. She was
already concerned about how she would pay for her GI consult if it was needed. She gave me the
impression she was not going to follow up with GI and would come for pain management every
time there was an issue. She stated at one point of her visit, “can you not just give me something
for the pain?” further education was provided but she didn’t see the need for a follow up with GI.
Evidence-based practice
According to The (international journal of general medicine, 2012) “We propose the use
of the following definition for acute abdominal pain: the pain of nontraumatic origin with a
maximum duration of 5 days.” Clinical evaluation is advised to differentiate between urgent and
nonurgent causes. The diagnostic accuracy of clinical assessment is insufficient to identify the
Abdominal Pain
correct diagnosis but can discriminate between urgent and nonurgent causes. Patients suspected
of nonurgent diagnoses can safely be reevaluated the next day. Based on current literature, no
conclusions can be drawn on the differences in accuracy between residents and specialists. No
conclusions can be drawn on the influence of a gynecological consultation. In patients suspected
of an urgent condition, additional imaging is justified. CRP and WBC count alone is insufficient
to discriminate urgent from nonurgent diagnoses. (Macaluso, C. & McNamara, M. 2017). There
is no place for conventional radiography in the work-up of patients with acute abdominal pain
due to the lack of added value on top of clinical assessment. Computed tomography leads to the
highest sensitivity and specificity in patients with acute abdominal pain. Positive predictive value
of ultrasound is comparable with CT and therefore preferred as the first imaging modality due to
the downsides of computed tomography; negative or inconclusive ultrasound is followed by CT.
(Macaluso, C. & McNamara, M. 2017).
Self-Reflection
I Did a good job with this patient. I say this because my preceptor agreed with my plan
after my visit and assessment on the patient. He especially gave me credit for wanting to get an
ultrasound before doing a further workup. I had a difficult time with educating the patient on
why she needed to go to GI because she was concerned about her insurance coverage and I had
no knowledge of what her insurance covered and what it didn’t. My preceptor had to step and
take over from there.
Advanced Practice Practitioner Role Analysis
As an advanced practice nurse, I will need to better understand how to approach each
patient encounter. Every encounter is different, and my mindset has to be the same. I can’t take
Abdominal Pain
what I learned or did in one room into the next depending on the presentation. I have to be
confident in my decision making as long as I follow protocol and my decisions are supported by
evidence-based practices. Nursing is based on the holistic platform and I need to make sure I am
well versed on everything concerning my patients including questions that may be non-medical.
(E.g., external stressors.)
Reference
Epocrates Essentials (2012) [PDA Medical Software]. San Mateo, CA: Epocrates.
Gutierrez, K. (2015). Pharmacotherapeutics: clinical reasoning in primary care (2nd ed.). St.
Louis, Mo: Saunders Elsevier.
O'Toole, P. (2017). Abdominal pain: Pathophysiology, etiology, diagnosis, and therapy. Topics
in Emergency Medicine, 24(1), 46.
Parswa. Ansari, (2018), Acute Abdominal pain. Assistant Professor and Program Director in
Surgery, Hofstra Northwell-Lenox Hill Hospital, New York
Camilleri. M, (2018). Boeckxstaens GDietary and pharmacological treatment of abdominal pain
in IBSGut 2017;66:966-974.
van Assen, T., Boelens, O. B., Kamphuis, J. T., Scheltinga, M. R., & Roumen, R. M. (2012).
Construction and validation of a questionnaire distinguishing a chronic abdominal wall
pain syndrome from irritable bowel syndrome. Frontline gastroenterology, 3(4), 288-294.
Abdominal Pain
Weston, G., Rothe, M. J., Kels, B. D., & Grant-Kels, J. M. (2016). The good, the bad, and the
ugly of medication coverage: Is altering a diagnosis to ensure medication coverage
ethical?. International journal of women's dermatology, 2(2), 67-68.
doi:10.1016/j.ijwd.2016.02.002
Macaluso, C. & McNamara, M. (2017). Evaluation and management of acute abdominal pain in
the emergency department. International journal of general medicine, 5, 789-97.