Diagnosing Abdominal Pain for New Nurse Practitioners
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Show notes:
Some chief complaints in primary care are more stressful than others. Abdominal pain is CERTAINLY one of them, especially for new nurse practitioners.
Diagnosing Abdominal Pain in Primary Care
In this video, I give my top systematic hacks for diagnosing abdominal pain in the primary care setting to make sure you’re not missing anything and are providing safe care.
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well hey there it's liz rohr from real
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world np and you're watching mp practice
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made simple the weekly videos to help
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save you time
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frustration and hope you learn faster so
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you can take the best care of your
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patients
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so today i'm going to be talking to you
ABDOMINAL PAIN HACKS
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about abdominal pain hacks
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the general kind of approach to
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diagnosis and management
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from like a very high level perspective
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to really help just make it easier
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right because it can be a little bit of
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an overwhelming symptom to be addressing
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especially as a brand new grad or as an
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np
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student so um the first general thing
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is triage right is this an acute problem
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that is dangerous and needs to go to the
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er
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or is this something that's um you know
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could potentially still be acute
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or chronic but can be managed in the
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outpatient setting on a more
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gradual basis right the main things to
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watch out for number one
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unstable vital signs right hypotension
UNSTABLE VITAL SIGNS
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tachycardia
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hypoxemia things like that you also want
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to watch out for signs of peritonitis
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and so the
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general signs of that are abdominal
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rigidity
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guarding and rebound and very like very
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intense pain with just very slight
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pressure
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um on exam and then the other thing to
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think about um are just any signs
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suggestive of like worst case scenario
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red flag diagnoses and this is again not
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comprehensive but
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for example things like um ectopic
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pregnancy bowel perforations
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acute small bowel obstruction things
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like that
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so things to kind of like generally keep
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in mesenteric ischemia another one
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appendicitis you know the whole list so
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having a general list of like what are
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those worst case scenario ones and like
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does it seem like it's presenting that
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way
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and number one potentially getting the
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assistance of a colleague or making the
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decision to send them to the er
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the next general approach that i
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recommend to kind of help make this a
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little bit easier
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one of the nice things is that now that
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i have several years of experience i can
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go into a room and i have differentials
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in my mind
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and when i'm coming into the room i'm
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pulling from those differentials and i'm
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asking the history questions
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based on that differential list but when
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you're new there's so much to think
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about even if you have those in your
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mind it's kind of stressful right
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and so that working backwards way is
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kind of like the next kind of hack so
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one
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is taking the same framework for every
TAKING THE SAME FRAMEWORK FOR EVERY VISIT
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single visit and i say this i feel like
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i say this all the time
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but it is really helpful so using an old
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cart framework or whatever framework you
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want but i use old cart
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onset location duration associated
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factors relieving factors and time
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characteristics i think i miss
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characteristics in there
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but using that general approach any
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single time i have a i have a symptom in
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front of
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in front of me especially if i'm not
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quite sure what to do because that will
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really give you a
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very pretty good picture to start um of
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what we're looking at the next kind of
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hack of like working backwards
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especially if you don't have those
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differentials in the front of your mind
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is just doing the full ros and i found
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that i had some ego when i was a new
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nurse practitioner i was trying to prove
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to myself and to my colleagues that i
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knew what i was doing
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you know and i was really good at this
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you know but like a lot of it you kind
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of just have to put your ego aside and
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just do it for the safe care right
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excellent safe care is the most
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important thing so for me
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i literally brought in a piece of paper
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with a checklist like a copy of a
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checklist
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of like questions to ask because i was
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so nervous
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right and you can have that in your ehr
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wherever it is but there's no shame in
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bringing this into the room because it's
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all about safe care
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right so going through the full ros for
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a gi symptom
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all of the questions right nausea
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vomiting diarrhea
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constipation jaundice like et cetera et
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cetera going through that whole list
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and then thinking about the associated
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body systems that are not just gi
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right because i think that's one of the
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intimidating things about abdominal pain
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the wide differential diagnosis list
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list in addition to
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the fact that presentations are not
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always textbook you know
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so going into those associated um body
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systems and just asking all those
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questions constitutional right
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fevers chills weight loss etc cetera
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gu urinary symptoms remembering um you
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know the
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uterus and ovaries depending on what
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organs that that person has
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what about those systems what questions
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you want to ask all of them just ask all
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of them
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and then cardiac and pulmonary i think
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are some sneaky ones sometimes that
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we're so focused on abdominal etiologies
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that we forget sometimes that it's
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cardiac and pulmonary as well and again
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even if you don't have those diagnoses
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in the front of your mind
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when you ask those full ros questions it
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will help you get there and help you
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remember to think about that
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and then the next thing um has to do
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with two other kind of like main tip
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hacks one is looking at the abdomen in
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terms of quadrants
LOOKING AT ABDOMEN IN TERMS OF QUADRANTS
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so maybe this is not news to you but
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actually nine sections
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so on the top row um epigastric and
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right upper quadrant left upper quadrant
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on both sides or
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whatever way that is i don't know
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mirroring backwards with the camera
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um a peri umbilical in the middle with
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flanks on either side
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super pubic at the bottom and left lower
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quadrant and right lower quadrant
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um keeping those in mind when we're
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talking about the abdominal pain and
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again maybe that's obvious but
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i find it really helpful to narrow that
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down because it helps me understand and
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remember
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the organs underneath those quadrants
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right so if we're
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talking about suprapubic um pain we're
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looking at bladder
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uterus ovaries potentially prostate
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ureters like things like that you know
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and you can come up with your
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differential diagnosis list for each of
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those quadrants
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keeping in mind that you can have
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referred pain from another quadrant
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right for example cholecystitis
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right upper quadrant pain typically is
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like the classic textbook right which is
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not always the real world
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but you can have that sharp intense pain
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in the right upper quadrant
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but additionally you'll also see
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presentations where it's entire band on
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the top of the abdomen right
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so keeping all of that stuff in mind i
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think the last kind of tip the general
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last general tip that i have about
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approaching abdominal pain
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is actually a question that my primary
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care asked me
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i had severe epigastric pain when i was
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a brand new nurse practitioner turns out
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it was stress related despite all of the
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work up and the treatments and the blah
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blah blah
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anyway that is neither here nor there
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but the question that she asked me was
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like what does it look like in your
WHAT DOES IT LOOK LIKE IN YOUR DAILY LIFE?
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daily life and i thought she was just
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being like a holistic
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and really sweet which she is she's a
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wonderful clinician
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so so special and she was
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but also i think one of the important
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things that i missed
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the full picture of when i was a new
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grad it's like easy to go in and say you
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know what you have epigastric pain
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here's the differential diagnosis ask a
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couple of questions i'm like okay i'm
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just going to jump right into the
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history and right into the lab tests and
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potentially some imaging
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and i want to stress to you that the the
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more history detailed history that you
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can get
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the more quickly you will get your
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diagnosis
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it'll be a lot more clear and then you
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get your treatment sooner and the
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patient's relief sooner right
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so this question of like it doesn't have
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to specifically only be that question
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but
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the gist i'm trying to get at with you
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is like can you picture it in your mind
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right because it's easy to go from oh my
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gosh
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epigastric abdominal pain here's the
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work up that i need to do versus okay do
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you wake up with it do you go to bed
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with it is it on the weekends is it the
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weekdays how long does it last for i
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mean you've asked those old card
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questions but like
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can you visualize in your mind what this
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looks like and i actually find that
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patients have a hard time
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describing that sometimes so i think
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it's it goes one of two ways some people
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are kind of surprised by it they have to
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think about and then other people are
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like
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this yes you know and i think that like
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kind of like one point to add on is that
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like
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i think a lot of the times new grads
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really worry about
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missing something large because they
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forgot to ask about something small or
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didn't notice something small
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and things happen right everything
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anything is possible right
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but the vast majority of the time when
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you have more serious ideologies
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they're gonna present seriously if that
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makes sense so
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so yeah so if i can if i can leave you
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with that hopefully hopefully that is
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helpful
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next week i'm actually going to be
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talking about a red flag diagnosis
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pancreatitis
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um and how to evaluate that including
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the lab so definitely stay tuned for
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that please let me know what questions
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you have
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very much for watching hang in there and
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i'll see you soon
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[Music]
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