abdominal pain which test is best - nysena.org · • a chest-xray did not disclose a fracture. the...
TRANSCRIPT
Objectives
• Upon completion of this program, participants will be able to:
• 1. Define the term “Acute Abdomen” • Discuss the importance of the clinical patterns • Discuss rational for diagnostic test • Review two case studies
Acute Abdomen
• Abdominal pain of short duration < 24 hours • That requires consideration of surgical
intervention • Non- specific – Abdominal pain is :
Clinical Patterns
• The clinical pattern helps the NP decide on a course of action from a limited list of management options
A Step wise Approach
• A stepwise approach to abdominal pain requires identification of specific high-risk populations. In low-risk patients, the pain location guides the initial differential diagnosis. Several areas of the abdomen deserve special attention because the clearest evidence for a consistent work-up is in these areas.
Geographical Location
• Consider your geographical location and the pattern of practice
• High incidence of: • ETOH Abuse • Cocaine / Opioids abuse • Elder Nursing Home patient
Get Physical
• Subjective History • Hands on exam
Farting…
Example
• Abdominal Pain • Small bowel obstruction • Vomiting • Diarrhea • GI Bleeding
Abdominal Pain
• Determine the cause • Taking a good history • Onset • Location • pattern • Duration of the pain • What makes the pain worsen or better • Physical exam
stomach ache
Cramps or a dull ache Self-limiting and resolve quickly Severe abdominal Organs Severe abdominal Intervention Fully investigated.
Red Flag
• Potential causes of abdominal pain including
red flagged or "don’t miss" diagnoses which should be ruled in or ruled out quickly, as they could require urgent medical/surgical intervention
Rational for Diagnostic Test
VOMIT
• V- Victim • O- of • M- Modern • I- Imaging • T- Technology
Protocols
• The patient comes in and based on the protocol, without a physical exam is sent straight to:
• CT • FAST • CXR
Read the Report
• Missed Diagnosis
• Incidental findings
Case study #1
• A college student injured in an automobile crash at 11:30 p.m. was taken to a small, isolated hospital where a surgeon attended to the fractured ribs and sternum. A chest tube was inserted to drain the fluid that had accumulated in his thoracic cavity. Chest X-rays did not demonstrate any re-accumulation of fluid or findings consistent with major blood vessels injury.
Cont. Case 1
• Although it would have been appropriate to perform a CT scan to determine if there had been any injury to the thoracic aorta as a result of the impact, the rural hospital’s CT scan machine was out of service and a technician would not be available to service it until 9:00a.m.
Cont. Case 1
• The surgeon choose to keep the patient for observation and stabilization. By 7:00 am, the
• Patients clinical condition had improved so much that he insisted on being allowed to return to college. Upon being discharged from the hospital, the surgeon the surgeon told him to select a physician in his college town and have that physician consult a surgeon.
Cont. Case 1
• After returning to school the patient did not consult another physician, even though he continued to experience chest pain because he assumed it was a result of his fractured sternum. Several weeks later, the progression and persistence of the pain caused him to consult a physician. This physician examined him and referred him to a cardiovascular surgeon, who admitted him to a medical Center for immediate surgery.
Cont. Case 1
• During the operation, the thoracic aorta ruptured. Resulting in uncontrollable hemorrhage and death
• The patients mother sued the surgeon that attended to her son immediately after the car crash, contending that her should have been transferred to a facility with a functional CT Scan machine so that the traumatic aortic aneurysm could have been diagnosed
Case #2
• A dockworker was struck in the lower chest by a heavy cable and was evaluated by a nurse practitioner at a company clinic. The NP reassured her that nothing was broken and told her that she was just “scared”. She was given an oral analgesic and sent back to work.
Cont. Case #2
• The patient returned to the clinic the following morning and was examined by the same NP. This time, the Patient complained of shoulder and mid-dorsal pain and reported “spitting up” blood during the night. The NP considered intra- abdominal hemorrhage. Never the less, she recorded that the patient had a “voluntary reaction” to his abdominal examination and that she was a “difficult patient”. When the patient told the NP that it was painful for her to lie down on the X-ray table, the NP suspected a “hysterical reaction”
•
Cont. Case 2
• A chest-xray did not disclose a fracture. The NP did not instruct her to return to the clinic. Nor did she place any limitations on her activities.
• Several hours after returning to work, the patient became ill and was transported to an emergency department. The ED physician evaluation disclosed exquisite left upper quadrant tenderness and referred rebound pain indicative of peritoneal irriation.
Cont. Case #2
• The hematocrit was 22 and the hemoglobin was 7. Serum transaminase and amylase were elevated. The abdominal F.A.S.T was positive for fluid. An exploratory laparotomy disclosed
• Intraperitional hemorrhage secondary to laceration of the left lobe and sub-diaphragmatic surface of the liver. The patient
• Experienced a prolonged recovery process and sued the clinic NP.
What to Do with the Patient
• Surgery stat • Surgery tonight • Admit for observation /ABX/ Serial exam • Discharge Home
1. Abdominal pain and shock
• AAA rupture • Ectopic Pregnancy rupture • Trauma – OR Stat
2. Diffuse Peritonitis
• Perforated Ulcer • Dead Bowel • Perforated Diverticulitis
3. Localized Peritonitis
• Admit Appendicitis • Cholecystitis • Diverticulitis • Redundant Sigmoid
4. Bowel Obstruction
• Adhesions • Incarcerated Hernia
Reason for unnecessary Test
• Ignorance • Lack of confidence • Laziness
Unnecessary Test
• “God gave you ears, eyes and hands: Use them on the patient in that order”
Unnecessary Test
Evaluation of RLQ pain
Recommended Imaging Studies Based on Location of Abdominal Pain
Location of pain Imaging Right upper quadrant Ultrasonography Left upper quadrant CT Right lower quadrant CT with IV contrast media Left lower quadrant CT with oral and IV contrast media Suprapubic Ultrasonography
Non- Specific Abdominal pain
• Abdominal pain of short duration • Work up negative • Patient does not come back
Recommended Imaging Studies Based on Location of Abdominal Pain
• Location of pain Imaging :
• Right upper quadrant • Ultrasonography • • Left upper quadrant • CT • • Right lower quadrant • CT with IV contrast media • • Left lower quadrant • CT with oral and IV contrast media
• Suprapubic • Ultrasonography
How you order a CT examination
• When to use contrast • When type of contrast : PO, IV, Rectal
References • 1. Advance NP & PA’s Newsmagazine– www.advanceweb.com • Evaluation of the Acute Abdomen Key issues in primary care settings • By Bruce S. Zitkus, NP
• 2. Evaluation of the Acute Abdomen- Text Acute Care surgery, Greto L. Piper, Mathew R.
Rosingart, Andrer B. Peizman, Raquel Forsythe , Chapter 33page 471 • Publisher Lippincott Williams & Wilkins 2012 ISBN-13978160831-428-7 • 3. Test to Determine the cause of Abdominal pain – Charlene Collins • Sources: • http:www.medicinenet.com/abdominal pain/article.htm • http:ww. Wrongdiagnosis.com/sym/cold skin.htm • http://www.en.wikipedia.org/wiki/Magnetic resonance imaging
QUESTIONS
