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

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NR511 Final Exam

Study Guide

WEEK 1

1. Define diagnostic reasoning

-To solve problems, to promote health, and to screen for disease or illness all require a sensitivity to complex stories, to contextual factors, and to a sense of probability and uncertainty.

-Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves the process of questioning one’s thinking to determine if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence.

Diagnostic reasoning then includes a systematic way of thinking that evaluates each new piece of data as it either supports some diagnostic hypothesis or reduces the likelihood of others.

2. Discuss and identify subjective & objective data

-Subjective:

-reports

-complains of

-tells you in response to your questions.

-Includes ROS, CC, and HPI

-Objective:

-what you can see, hear, or feel as part of your clinical exam.

-It also includes laboratory data and test results.

3. Discuss and identify the components of the HPI

-O: Onset of CC

-L: Location of CC

-D: Duration of CC

-C: Characteristics of CC

-A: Aggravating factors for CC

-R: Relieving factors for CC

-T: Treatments tried for CC

-S: Severity of CC

4. Describe the differences between medical billing and medical

coding

Medical coding: is the use of codes to communicate with payers about which procedures were performed and why.

-Medical billing: is the process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider.

5. Compare and contrast the 2 coding classification systems that are

currently used in the US healthcare system

-The CPT system offers the official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and non- physician providers.

-CPT codes are recognized universally and also provide a logical means to be able to

track healthcare data, trends, and outcomes.

-ICD-10 codes are shorthand for the patient’s diagnoses, which are used to provide the payer information on the necessity of the visit or procedure performed.

6. Discuss how specificity, sensitivity & predictive value

contribute to the usefulness of the diagnostic data

-Specificity of a test, we are referring to the ability of the test to correctly detect a specific condition.

-Predictive value is the likelihood that the patient actually has the condition and is, in part, dependent upon the prevalence of the condition in the population.

-When a test is very sensitive, we mean it has few false negatives.

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

plan

Acknowledge the list

-Negotiate what to cover

-Be Honest

-Make a follow-up

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

coding

• There are three key components that determine risk-based E&M codes.

-History

-Physical

-Medical Decision Making (MDM) E&M coding requires a medical decision

maker

-Medical decision making is another way of quantifying the complexity of the thinking that is required for the visit.

-Complexity of a visit is based on three criteria:

-Risk

-Data

-Diagnosis

-Now, medical decision making is a special category. Why is this so important? Well, the MDM score gives us credit for the excess work involved in management of a more complex patient.

9. Correctly order the E&M office visit codes based on complexity

from least to most complex

99212 - 99214

10. Discuss a minimum of three purposes of the written history

and physical in relation to the importance of documentation

-It is an important reference document that gives concise information about a patient's history and exam findings.

-It outlines a plan for addressing the issues that prompted the visit. This information should be presented in a logical fashion that prominently features all data immediately relevant to the patient's condition.

-It is a means of communicating information to all providers who are involved in the care of a particular patient.

-It is an important medical-legal document

-It is essential in order to accurately code and bill for services.

11. Accurately document why every procedure code must have a

corresponding diagnosis code

-Every procedure code needs a diagnosis to explain the necessity whether the code represents an actual procedure performed or a nonprocedural encounter like an office visit.

12. Correctly identify a patient as new or established given the

historical information

- Patient status

-New patient: one who has not received professional service from a provider from the same group practice within the past 3 years.

-Established patient of your practice: has received professional service from a provider of your office within the last 3 years

13. Identify the 3 components required in determining an outpatient,

office visit E&M code

-Place of service -Type of service

-Inpatient - Consultation’s

-Outpatient -Office visit

-Hospital admission

-Patient status

-New patient: one who has not received professional service from a provider from the same group practice within the past 3 years.

-Established patient of your practice: has received professional

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

coding

• There are three key components that determine risk-based E&M codes.

-History

-Physical

-Medical Decision Making (MDM) E&M coding requires a medical decision maker

-Medical decision-making is another way of quantifying the complexity of the thinking that is required for the visit.

-Complexity of a visit is based on three criteria:

-Risk

-Data

-Diagnosis

-Now, medical decision making is a special category. Why is this so important? Well, the MDM score gives us credit for the excess work involved in management of a more complex patient.

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

-Includes both children from birth through young adult visits for well child and acute visits, as well as adults for wellness and acute or routine visits

16. State the maximum number of hours that time can be spent

“rounding” in a facility

<25%

17. State 9 things that must be documented when inputting

data into clinical encounter

• date of service - visit E&M code (e.g., 99203) - age
• gender and ethnicity - chief concern - procedures
• tests performed or ordered - diagnoses - level of involvement

18. Identify and explain each part of the acronym SNAPPS

-S: Summarize

-N: Narrow

-A: Analyze

-P: Probe

-P: Plan

-S: Self-directed learning

WEEK 2

1. Identify the most common type of pathogen responsible for acute

gastroenteritis

-Viral: Norovirus (Leading cause for adults)

-Rotovirus (Leading cause for peds up to 2 years old)

2. Recognize that assessing for prior antibiotic use is a critical part

of the history in patients presenting with diarrhea

Due to risk of C Diff infection

3. Describe the difference between Irritable Bowel Disease (IBS)

and Inflammatory Bowel Disorder (IBD)

• IBS (Irritable bowel syndrome): disorder of bowel function not from anatomic abnormality

-constipation, diarrhea, bloating, urgency w/ diarrhea

-NOT assoc w/ serious medical consequences, IBD or CA

+S/S: result from disordered sensation or abnormal function of the small and large bowel

• IBD (Inflammatory bowel disease): chronic immunologic disease that manifests in intestinal inflammation
  • UC/CD

4. Discuss two common Inflammatory Bowel Diseases

• Ulcerative colitis (UC ): the mucosal surface of the colon is inflamed and ultimately results in friability, erosions, and bleeding.
  • Most common in recto-sigmoid colon. Can involve entire colon
  • Pain in RLQ
• Crohns (CD ): the inflammation extends deeper into the intestinal wall and can involve all or any layer of the bowel wall and any portion of the GI tract from the mouth to the anus.
  • Skipped lesions
  • Pain in LLQ

5. Discuss the diagnosis of diverticulitis, risk factors, and treatments

Symptoms: LLQ pain/ tenderness, fever, N/V/D

Need imaging especially if perforation or peritonitis is suspected; free air = perforation; patient may have ileus, small or large bowel obstruction

Can use plain x-ray

CT or barium enema are preferred

CT with contrast is more sensitive and accurate

6. Identify the significance of Barrett’s esophagus

After repeated exposure to gastric contents, inflammation of the esophageal mucosa becomes chronic.

· Blood flow increases, erosion occurs

· As erosion heals, normal squamous epithelium replaced with metaplastic columnar epithelium containing goblet and columnar cells

· More resistant to acid and supports esophageal healing · Premalignant tissue · 40-fold risk for development of esophageal adenocarcinoma · Fibrosis and scarring during healing of erosions; leads to strictures

7. Discuss the diagnosis of GERD, risk factors, and treatments

• Diagnosis made on history alone; sensitivity of 80%
• If symptoms are unclear/patient doesn’t respond to 4 weeks of empiric treatment
• Dx made by ambulatory esophageal pH monitoring
• pH < 4 above the lower esophageal sphincter and correlates with symptoms = GERD
• EGD with biopsy – Barrett’s esophagus
• Normal results in 50% of symptomatic patients
• Risks o Obesity o Increases after age 50 o Equal across gender, ethnic, and cultural groups
• Treatment o Small, frequent meals – main meal at midday o Avoid trigger foods o No bedtime snacks; no eating < 4 hours prior to bed o Eliminate caffeine o Stop smoking o Avoid tight fitting clothing o Sleep with head elevated
• Medication: o Step 1: antacids or OTC H2 (Tagamet, zantac, axid) o Step 2: Rx-strength H2 (ranitidine 150mg BID, famotidine 20mg BID) or PPI (pantoprazole 40mg daily, omeprazole 20mg daily) o Step 3: PPI (omeprazole 40mg daily) o Step 4: surgery (fundoplication)

8. Discuss the differential diagnosis of acute abdominal pain, work-

up and testing, treatments

Diff Diagnosis

Acute appendicitis:

▪ Inflammation of the vermiform appendix; due to obstruction or infection

▪ Most common surgical emergency of the abdomen

▪ Hollow tube – most common cause is obstruction of appendix

▪ Fecaltih – hard lump of fecal matter

▪ Undigested seeds

▪ Pinworm infections

▪ Lymphoid follicle growth/lymphoid hyperplasia Symptoms

▪ Symptoms

▪ Nausea/vomiting

▪ RLQ pain

▪ Guarding

Acute pancreatitis:

▪ Sudden inflammation and hemorrhaging of the pancreas due to destruction by its own digestive enzymes

1. Autodigestion

▪ Most of the time mild, but can be severe

▪ Pancreas

▪ Long skinny gland, length of dollar bill

▪ Located in upper abdomen

▪ Behind the stomach

▪ Endocrine

▪ Alpha/beta cells produce insulin & glucagon that are secreted into the blood stream

▪ Exocrine

▪ Leading causes:

1. ETOH abuse
2. Gallstones
3. Other Causes of acute pancreatitis

1. I Get Smashed

▪ I – idoipathic

▪ G- gallstones

▪ E- ETOH abuse

▪ T – trauma

▪ S – steroids

▪ M – mumps virus

▪ A – autoimmune diseases

▪ S – scorpion stings

▪ H – hypertriglyceridemia & hypercalcemia

▪ E – ERCP

▪ D – drugs

Symptoms

Nausea

▪ Vomiting ▪ Hypocalcemia ▪ Cullen’s sign – bruising around umbilicus ▪ Grey-Turner’s Sign - Bruising along flank ▪ Necrosis induced hemorrhaging spreads

Acute cholecystitis:

Inflammation of gallbladder (GB) Usually due to gallstone in cystic duct

1. Cystic duct – leaves gall bladder & connects to common bile duct

Symptoms:

Patient will have mid-epigastric pain

▪ Because GB is still squeezing, increasing pressure w/ nowhere for bile to go

▪ Can lead to nausea/vomting

▪ Stone can get more stuck w/ more squeezing Bile

starts to irritate mucosa

Mucosa starts to produce mucous and inflamm enzymes

▪ Leads to inflammation, distention, pressure build up

▪ Bacterial growth (E. coli, enterococci, bacteroides fragilis, colstriduim) As

GB “balloons”, pain shifts to RUQ, R scapula/shoulder

Bacteria invades in & through GB wall, into peritoneum, causing

peritonitis

▪ Rebound tenderness

Murphy’s Sign = Put pressure on right side under ribs. This will hold GB in place. Have patient take a deep breath. The diaphragm will push on the GB & a painful response = Cholecystitis

Immune response

▪ Neutrophilic leukocytosis

▪ Fever

Workup and testing : All patients with abdominal pain should undergo rectal, gential, and pelvic exam. It is important to isolate the location of the pain.

Acute appendicitis:

▪ Diagnosis is made clinically and based on history and physical

▪ Elevated WBC

▪ Mild Fever, 99-

▪ RLQ pain/McBurneys point

▪ CT abd may help rule out other diagnostic possibilities

▪ ABD ultrasound helps to visualize the inflamed appendix

Acute pancreatitis:

▪ Pain in epigastrium which radiates to back

▪ Labs

▪ Increase in amylase; gold standard in diagnoses (up to 3x the normal level)

▪ Increase in lipase

▪ CT scan

▪ US to look for gallstones

Acute cholecystitis:

▪ US confirmed

▪ Detects stones

▪ Sonographic murphy sign

▪ Tenderness when sonogram is over gallbladder

▪ GB wall thickening

▪ Sludge

▪ Distention of GB or common bile duct

▪ Cholescintigraphy (HIDA scan)

▪ Radiolabeled marker used to visualize the biliary system

▪ Acute cholecys – ducts are blocked, GB can’t be seen

▪ Endoscopic Retrograde Cholangiopancreatography (ERCP)

▪ Endoscope down to pancreas

▪ Dye injected & viewed via fluoro

▪ Magnetic Resonance Cholangiopancreatography (MRCP)

▪ Visualizes bili system with MRI

Treatment:

Acute appendicitis:

• Appendectomy
• Antibiotic
• Drain abscesses
• Can be removed prophylactically

Acute pancreatitis:

o pain management

o hydration

o electrolytes

o rest bowels

▪ NPO

▪ IV nourishment

o Treat complications

▪ O2

▪ ATB

Acute cholecystitis:

o Supportive measures

▪ IV

▪ Pain management

▪ ATB

o Surgical Removal

▪ Cholecystectomy

1. Laparoscopic

9. Discuss the difference between sensorineural and conductive

hearing loss

• Sensorineural: Results from deterioration of cochlea

-Loss of hair cells form the organ of Corti

-Gradual and progressive

-Not correctable but preventable

• Conductive: Obstruction between middle and outer ear

-Most types are reversible

10. Identify the triad of symptoms associated with Meniere's disease

• Meniere’s Disease: Sensory disorder of labyrinth (semi-circular canal system) and cochlea

-S/S:

-Vertigo

-Hearing loss

-Tinnitus

11. Identify the symptoms associated with peritonsilar abscess

-Increasing unilateral ear and throat pain ipsilateral to the affected tonsil

-Dysphagia

-Drooling

-Trismus

-Erythema

-Edema of the soft palate with fluctuance on palpation

12. Identify the most common cause of viral pharyngitis

-Adenovirus: MOST common -RSV

-Influenza A&B -Epstein-Barr

-coxsackie -enteroviruses

-herpes simplex

13. Identify the most common cause of acute nausea & vomiting

Gastroenteritis

14. Discuss the importance of obtaining an abdominal xray to rule

out perforation or obstruction even though the diagnosis of

diverticulitis can be made clinically

Abdominal xray films should be obtained on all patients with suspected diverticulitis to look for free air (indicating perforation), ileus, or obstruction

15. Discuss colon cancer screening recommendations relative to

certain populations

-Anyone over age 50 should have a routine c-scope

-African American’s should start screenings at age 40

-Individuals with a single first-degree relative with CRC or advanced adenomas diagnosed at age ≥60 years can be screened like average-risk persons.

**Red flag symptoms should be sent to GI – unintentional weight loss, rectal bleeding, diffuse lower abdomen pain, new onset diarrhea/constipation, early satiety, loss of appetite

16. Identify at least two disorders that are considered to be

disorders related to conductive hearing loss

-Chronic Otitis Media (OM)

-middle ear effusion

-mass

-vascular anomaly

-cholesteatoma – abnormal noncancerous skin growth in ear canal

17. Identify the most common bacterial cause of pharyngitis

-Group A Beta Hemolytic Streptococcus (GABHS)

-Absence of cough

-Tonsillar exudates

-History of fever

-Tender anterior cervical adenopathy

18. Identify the clinical findings associated with mononucleosis