Differential Diagnosis and Management of Acute Abdominal Pain, Exams of Nursing

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WEEK 1

1. Define diagnostic reasoning

Reflective thinking because the process involves questioning one's thinking to determine if all possible avenues have been explored & if the conclusions that are being drawn are based on evidence.

Seen as a kind of critical thinking.

2. Discuss & identify subjective data? What the patient tells you, complains of, etc. Chief complaint

HPI ROS

3. Discuss & identify objective data?

What YOU can see, hear, or feel as part of your exam. Includes lab data, diagnostic test results. Components of HPI

4. Discuss & identify the components of the HPI Specifically related to the chief complaint only. Detailed breakdown of CC. OLDCART

5. What is medical coding?

The use of codes to communicate with payers about which procedures were performed & why

6. What is medical billing?

Process of submitting & following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider.

7. What are CPT codes?

Common procedural terminology

Offers the official procedural coding rules & guidelines required when reporting medical services & procedures performed by physician & non-physician providers.

8. What are ICD codes?

International classification of disease

Used to provide payer info on necessity of visit or procedure performed.

9. What is specificity?

The ability of the test to correctly detect a specific condition.

If a patient has a condition but test is negative, it is a false negative.

If a patient does NOT have a condition but the test is positive, it is a false positive.

10. What is sensitivity?

Test that has few false negatives.

Ability of a test to correctly identify a specific condition when it is present. The higher the sensitivity, the lesser the likelihood of a false negative.

11. What is predictive value?

The likelihood that the patient actually has the condition & is, in part, dependent upon the prevalence of the condition in the population.

If a condition is highly likely, the positive result would be more accurate.

12. Discuss the elements that need to be considered when developing a plan

Pt's preferences & actions Research evidence

Clinical state/circumstances Clinical expertise

13. Describe the components of Medical Decision Making in E&M coding

Risk Data

Diagnosis

The more time & consideration involved in dealing with a pt, the higher the reimbursement from the payer.

Documentation must reflect MDM!

evaluation & management (E&M)

14. Correctly order the E&M office visit codes based on complexity from least tomost complex

New patient: Established patient:

1. Minimal/RN visit: 99201 Minimal RN visit: 99211

_2. Problem focused: 99202 Problem focused: 99212

3. Exp&ed problem focused: 99203 Exp&ed problem focused: 99213
4. Detailed: 99204 Detailed: 99214
5. Comprehensive: 99205 Comprehensive: 99215_
   15. Discuss a minimum of three purposes of the written history & physical in relationto the importance of documentation

Important reference document that gives concise info about the pt's Hx & exam findings.

Outlines a plan for addressing issues that prompted the visit. Info should be presented in a logical fashion that prominently features all data relevant to the pt's condition.

Is a means of communicating info to all providers involved in the pt's care.

Is a medical-legal document.

Is essential in order to accurately code & bill for services.

16. Accurately document why every procedure code must have a corresponding diagnosis code

Diagnosis code explains the necessity of the procedure code. Insurance won't pay if they don't correspond.

17. Correctly identify a patient as new or established given the historical information If that pt has never been seen in that clinic or by that group of providers OR if the pt has not been seen in the past 3 years.

18. Identify the 3 components required in determining an outpatient, office visit E&Mcode

Place of service Type of service Patient status

19. Describe the components of Medical Decision Making in E&M coding

Risk Data

Diagnosis

The more time & consideration involved in dealing with a pt, the higher the reimbursement from the payer.

Documentation must reflect MDM!

evaluation & management (E&M)

20. Explain what a “well rounded” clinical experience means

Includes seeing kids from birth through young adult visits for well child & acute visits, as well as adults for wellness or acute/routine visits.

Seeing a variety of pt's, including 15% of peds & 15% of women's health of total time in the program.

21. State the maximum number of hours that time can be spent “rounding” in a facility

No more than 25% of total practicum hours in the program

22. State 9 things that must be documented when inputting data into clinical encounter

Date of service Age

Gender & ethnicity Visit E&M code CC

Procedures

Tests performed & ordered Dx

Level of involvement (mostly student, mostly preceptor, together, etc.)

23. What is the first “S” in the SNAPPS presentation?

Summarize: present the pt's H&P findings

24. What is the “N” in the SNAPPS presentation?

Narrow: based on the H&P findings, narrow down to the top 2-3 differentials

25. What is the “A” in the SNAPPS presentation?

Analyze: analyze the differentials. Compare & contrast H&P findings for each of the differentials & narrow it down to the most likely one

26. What is the first “P” in the SNAPPS presentation?

Probe: ask the preceptor questions of anything you are unsure of.

27. What is the second “P” in the SNAPPS presentation?

Plan: come up with a specific management plan

.

28. What is the last “S” in the SNAPPS presentation?

Self-directed learning: an opportunity to investigate more about any topics that you are uncertain of.

WEEK 2

1. What is the most common type of pathogen responsible for acute gastroenteritis?

Viral (can be viral, bacterial, or parasitic), usually norovirus

2. Assessing for prior antibiotic use is a critical part of the history in patients presenting with diarrhea. True

3. Describe the difference between Irritable Bowel Disease (IBS) & InflammatoryBowel Disorder (IBD)

IBS: disorder of bowel function (as opposed to being due to an anatomic

abnormality).

Changes in bowel habits (diarrhea, constipation, abd pain, bloating, rectal urgency w/diarrhea).

Symptoms fall into two categories: abd pain/altered bowel habits, & painless diarrhea. Usually pain is LLQ.

PE: normal except for tenderness in colon.

Labs: CBC, ESR. Most other labs & radiology/scopes are normal. Dx made on careful H&P.

May be associated with non-intestinal (extra-intestinal) symptoms (sexual function

difficulty, muscle aches/pains, fatigue, fibromyalgia, HAs, back pain, urinary symptoms).

Not associate with serious medical consequences. Not a risk factor for other serious GI dz's.

Does not put extra stress on other organs. Overall prognosis is excellent.

Major problem: changes quality of life.

Treatment: based on symptom pattern. May include diet, education, pharm (for mod- severe pt's)/other supportive interventions. Usually focuses on lifestyle, diet, & stress reduction. NO PROVEN TREATMENT! Antidiarrheals: use temporarily, reserve for severe. Loperamide (Imodium) or diphenoxylate (Lomotil) 2.5-5mg q6h usually works. Constipation: high fiber diet, hydration, exercise, bulking agents. If these don't work, intermittent use of stimulant laxatives (lactulose or mag hydroxide); don't use long- term! Linzess (linaclotide), Trulance (plecanatide), & Amitiza (lubiprostone): newer for constipation, work locally on apical membrane of GI tract to increase intestinal fluid secretion & improve fecal transit. Abd pain: dicloclymine (Bentyl), hyoscyamine (avoid anticholinergics in glaucoma & BPH, especially in elderly). TCAs & SSRIs can relieve symptoms in some pt's.

Can be managed by PCP, but if not responsive to tx, refer to GI.

IBD: chronic immunological dz that manifests in intestinal

inflammation. UC & Crohn's are most common.

UC: mucosal surface of colon is inflamed, resulting in friability, erosions, bleeding. Usually occurs in rectosigmoid area, but can involve entire colon. Ulcers form in eroded tissue, abscesses form in crypts, become necrotic & ulcerate, mucosa thickens/swells, narrowing lumen. Pt's are at risk for perforation. Symptoms: bleeding, cramping, urge to defecate. Stools are watery diarrhea with blood/mucus. Fecal leuks almost always present in active UC. Tenderness usually in LLQ or across entire abd.

Crohn's: inflammation extends deeper into intestinal wall. Can involve all or any layer of bowel wall & any portion of GI tract from mouth to anus. Characteristic segmental presentation of dz'd bowel separated by areas of normal mucosa ("skipped lesions").

With progression, fibrosis thickens bowel wall, narrowing lumen, leading to obstructions, fistulas, ulcerations. Pt's are at greater risk for colorectal cancer. Most common symptoms: cramping, fever, anorexia, wt loss, spasms, flatulance, RLQ pain/mass, bloody/mucus/pus stools. Symptoms increase with stress, after meals. 50% of pt's have perianal involvement (anal/perianal fissures).

Inflammation can lead to bleeding, fever, increased WBC, diarrhea, cramping. Abnormalities can be seen on cross-sectional imaging or colonscopy.

No single explanation for IBD. Theory: viral, bacterial, or allergic process initially inflames small or large intestine, results in antibody development which chronically attack intestine, leading to inflammation. Possible genetic predisposition.

Dx made by H&P correlated with symptoms, must exclude infectious cause for colitis. Primary dx tools: sigmoidoscopy, colonoscopy, barium enema w/small bowel follow- through, CT.

Tx is very complex, managed by GI.

Drugs: 5-aminosalicylic acid agents have been used for >50yrs, but have shown to be of little value in CD; still used as first attempt for UC. Antidiarrheals w/caution (constipation). Don't use in acute UC or if toxic megacolon. Corticosteroids used when 5-ASA not working. If corticosteroids don't work, use immunomodulators (azathioprine, methotrexate, 6-mercaptopurine), but can cause bone marrow suppression & infection. Newer class: anti-TNF (biologic response modifiers) for mod-severe dz. Remicade (infliximab), Humira (adalimumab), Entyvio (vedolizumab); can increase risk of infection.

4. Discuss two common Inflammatory Bowel DiseasesUC & Crohn's are most common. 5. Discuss the diagnosis of diverticulitis, risk factors, & treatments

Subjective:

S/S of infection (fever, chills, tachycardia) Localized pain LLQ

Anorexia, n/v

If fistula present, additional s/s will be present associated w/affected organ (dysuria, pneumaturia, hematachzia, frank rectal bleeding, etc)

Objective:

Tenderness in LLQ

Maybe firm, fixed mass at area of diverticuli

Maybe rebound tenderness w/involuntary guarding/rigidity

Hypoactive bowel sounds initially, then hyperactive if obstructive process present Rectal tenderness

+occult blood

Diagnostics:

Mild-moderate leukocytosis

Possibly decreased hgb/hct r/t rectal bleeding

Bladder fistula: urine will have increased WBC/RBC, culture may be + If peritonitis, blood culture should be done (for bacteremia)

Abd XR: perforation, peritonitis, ileus, obstruction CT may be needed to confirm

6. Identify the significance of Barrett’s esophagus.

A condition in which the esophageal lining is replaced by a tissue resembling intestinal lining. Squamous lining of lower esophagus turns into columnar epithelium (goblet cells).

Average age of onset: 55

1.6 – 6.8% of persons affected (5-10% of people with GERD get Barrett’s esophagus).

Risk Factors:

GERD

Obesity Smoking Age Gender Ethnicity

Signs/Symptoms:

1. Long-term indigestion-heart burn, fullness, bloating, belching
2. difficulty swallowing food
3. losing symptoms of GERD without doing anything

Diagnosis:

Upper endoscopy & biopsy if cells are present How to tx:

Medications (acid suppressing (proton pump inihibitors) Endoscopic ablative therapies

Endoscopic mucosal resection Esophagectomy

Increases Risk of BE:

H. pylori

NSAIDS & aspirins Diet & nutrition

Decreases Risk of BE:

Folate Vitamin E

Intake of Lutein

7. What is best test for diagnosing GERD? pH probe - Probe through nose, sits in esophagus for 24 hours - Constantly monitors pH

Heartburn is typical symptom. Usually occurs 30-60 min after meals & with reclining. Burning chest pain & regurgitation are common. Pain may be relieved by antacids. Most have no structural defects

Non-GI symptoms included asthma, chronic cough, laryngitis, sore throat or non- cardiac chest pain.

8. Risk factors of GERD: Obesity

Pregnancy Smoking

Collagen Vascular Disease ETOH use

Hiatal Hernia

Gender (more common in males)

9. How do we treat suspected GERD in patients with classic symptoms? Empiric therapy (PPI trial) is used both as a test & a treatment

Empiric therapy:

PPI once daily for 4-8 weeks

PPI are preferred over H2 receptor antagonists

PPI should be taken 30min before breakfast Many PPI's now over OTC formulations

10-20% will need twice daily PPI to get relief

Patients with good symptom control on empiric therapy s/b continued on PPI for 8- weeks.

1st line: life modification (elevate HOB, smoking cessation, avoid high fat/large meals, chocolate, ETOH, peppermint, caffeine, onions, garlic, citrus, tomatoes); don't sleep 3- 4hrs after meal, avoid bedtime snack.

Meds: avoid Ca blockers, beta blockers, alpha adrenergic agonists, theophylline, nitrates, some sedatives.

Encourage wt loss for overweight/obese pts

If lifestyle mods not working: step-up/down treatment guidelines for GERD. Mild, intermittent symptoms: trial for 4wks, if symptoms persist, step up:

1. Dietary/lifestyle mods

2. Antacid
3. OTC H2-RA: cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid)

Trial above for 6wks, if symptoms persist, step up +referral to GI:

1. Continue dietary/life mods
2. H2-RA Rx dosage: cimetidine 800mg TID, ranitidine 150mg TID, nizatidine 150mgTID, famotidine 20mg TID. OR PPI: omeprazole 20mg, rabeprazole 20mg, lansoprazole 30mg, esomeprazole 20mg, or pantoprazole 40mg daily.

Trial above for 8wks, if symptoms persist step up:

1. Diet/lifestyle mods
2. PPI increase to 40mg daily

Trial for 8wks, if symptoms persist, step up:

1. Diet/lifestyle mods
2. Surgical intervention 10. How do we treat suspected GERD in patients with “alarm symptoms”? EGD+/-PPI trial

-EGD good for finding complications of GERD (stricture, esophagits, barrett’s), but bad for looking at GERD itself. It misses non-erosive reflux disease (NERD).

11. What are “alarm symptoms” for patients with suspected GERD? Weight loss

Dysphagia Anemia Early satiety Bleeding

12. Clinical characteristics of GERD:

Heartburn Regurgitation

Water brash (reflex salivation) Dysphagia

Sour taste in mouth in the morning Odynophagia (painful swallowing) Belching

Coughing Hoarseness

Wheezing usually at night Substernal or retrosternal chest pain

Aggravating: reclining after eating, eating large meal, alcohol, chocolate, caffeine, fatty/spicy food, nicotine, constrictive clothes, heavy lifting, straining, bending over. Alleviating: antacids, sitting upright after meal, eating small meals

13. Discuss the differential diagnosis of acute abdominal pain, work-up & testing, treatments

One of the most frequent complaints in Primary Care: Abdominal Pain

Most Frequent cause of ABD pain in pediatric patients & common in all ages is: Nonspecific Abdominal Pain (NSAP)

Common Cause of Abd pain in RUQ: Hepatitis, GBD, Renal disease, Pylo, Renal stone

Common Cause of Abd pain in LUQ: Spleen, Renal disease

Common Cause of Diffuse Abd pain: IBD, IBS, Gastroenteritis, AAA, Bowel Obstruction, Ischemic Bowel

Common Cause of RLQ ABD pain: Appendicitis, PID, Ovarian Cyst, Ectopic Pregnancy

Common Cause of LLQ ABD pain: Ectopic Pregancy, Ovarian Cysts, Diverticulitis, PID

Common Cause of Epigastric ABD pain: MI, PUD, Biliary Disease, Pancreatitis

Common cause of Periumbilical Region: Early Appendicitis, Small bowel disease.

Terminology Signs:

Murphy's:

RUQ pain on deep inspiration: seen with inflamed gallbladder. May also be elicited by palpating the RUQ as they take a deep breath.

Signs of Peritoneal Irritation:

Guarding:

voluntary:

usually symmetric, muscles more tense on inspiration, usually does hurt to rise from supine to sitting position (using abd muscles), lessens with distraction.

involuntary:

asymmetrical, rigidity present on inspiration & expiration, rising to sitting position greatly increases pain, doesn't chg with distraction.

Rebound Tenderness: McBurney’s point

slowly compress abd, then quickly release pressure pain increases.

Lab Test for abdominal pain:

CBC (to look for infection & blood loss)

CMP: (check hydration with BUN, Cr, electrolytes, check LFT's for hepatitis or biliary disease)

Amylase/Lipase: (elevated in pancreatitis)

UA: (nitrates, leukocytes, RBCs may indicate UTI) Stool for occult blood: (cancer, IBD, diverticulitis, PUD)

Pregnancy test of all childbearing age females: (remember this even in young teens)

Imaging in Abd Pain:

KUB :

may detect renal stones, look for stool in colon free air in perforation, dilated loops of bowel in obstruction)

Abdominal US:

look for gallstones, ovarian cysts or ectopic pregnancy, hydronephrosis due to renal stone, high specificity for appy but not as sensitive as CT.

CT:

MOST sensitive test for diagnosing acute abd pain. Useful in appy, abscesses, AAA, diverticulitis, SBO, tumors.

DISORDERS CAUSE BY INFLAMMATION OF THE GI TRACT

"ACPGD"

Appendicitis Cholecystitis Pancreatitis Gastroenteritis Diverticulitis

APPENDICITIS SYMPTOMS/ IMAGING:

Symptoms:

anorexia, periumbilical pain that later migrates to RLQ, N/V usually after onset of pain, prefers to remain still

Signs:

pain at McBurney's pain (RLQ), rebound tenderness, + obturator, rovsing & iliopsoas signs, involuntary abd guarding( rigidity)

WBC: may be normal or slightly elevated

Diagnositic Imaging:

US very specific but not as sensitive as CT, useful in females to rule out gyn causes.

CT more sensitive

If high suspicion of Appy, some surgeons forego imaging prior to surgery. CHOLECYSTITIS, SYMPTOMS/IMAGING

Acute or Chronic inflammation of the GB

Symptoms develop from mechanical obstruction, local inflammation or a combination of these factors

Pain is colicky located in the RUQ with radiation to the flanks & occasionally Right shoulder pain

Classic pain occurs within 1 hour after eating a large meal, lasts for several hours, & is

followed by a residual aching that can last for days.

May have anorexia, nausea, & fever & less often with vomiting

RUQ US: has a sensitivity > 95% in detecting stones in GB

Treatment: Bowel rest, pain management , ABX & Surgery after infection is controlled.

PANCREATITIS SYMPTOMS

Risk:

hx of gallstones, heavy etoh use, hypertrigylceridemia, abd trauma. May be a hx of recent heavy drinking or a large meal prior to attack.

Symptoms:

abrupt onset of severe epigastric pain that may radiate to the back. N/V, sweating & anxiety. Pain is movement or lying supine & patient prefers to sit up & lean forward.

Signs:

abd tenderness w/o guarding, rigidity or rebound. Distension, fever, tachycardia, absent bowel sounds, pallor & hypotension may be present

Labs:

Amylase & Lipase elevated 3x normal, CT if unsure

Imaging:

KUB, CT if unsure

REFER!!!!!!

GASTROENTERITIS SYMPTOMS

Acute infectious diarrhea

70-80% d/t viruses such as Rotovirus, Adenovirus or Norvo virus after ingestion of contaminated food or water or by person-to person spread.

10-20% d/t bacterial infections: S. aureus, Calmonella, Shigella, C-diff, Vibrio, E coli after ingestion of contaminated foods or antibiotic exposure (C-difficile)

< 10% d/.t parasites: Giardia, Cryptospridium, Entamoeba histolytica: look for daycare attendance or camping (untreated water)

Usually self-limiting. Very young or elderly at more risk for complications

Symptoms:

Viral:

Large Volume, watery stools, no blood, Last 1-2 days, assoc N/V, crampy ABD pain, fever, malaise, dehydration in young children.

Bacterial:

variable from mild symptoms to severe, may have bloody diarrhea. C. Difficile may occur up to 8 weeks after exposure to antibiotics, esp. clindamycin, with watery diarrhea & cramps.

Parasitic:

watery diarrhea which may be prolonged, cramps

GASTROENDTERITIS TREATMENT:

Treatment is supportive for most

Assess Dehydration

Testing with stool culture not needed if less than 3 days duration unless <3 mo or > 70 years or at risk of transmitting to others.

Treatment:

oral hydration for all ages with mild to moderate diarrhea. Infants & children may continue diet for age, adults should avoid dairy caffeine & alcohol & eat rice, potatoes, wheat, bananas, yogert & soup & crackers.

Antimotility agents such as Lomotil or Imodium for adults only

Antibiotics if bacterial cause is suspected

DIVERTICULITIS ESSENTIALS OF DIAGNOSIS