Transcript: Diagnosing Abdominal Pain for New Nurse Practitioners

Transcript:

Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP, and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. So today, I'm going to be talking to you about abdominal pain hacks, the general kind of approach to diagnosis and management from like a very high level perspective to really help just make it easier. Because it can be a little bit of an overwhelming symptom to be addressing, especially as a brand new grad or as an NP student.

Liz Rohr:
So the first general thing is triage. Is this an acute problem that is dangerous and needs to go to the ER, or is this something that could potentially still be acute or chronic, but can be managed in the outpatient setting on a more gradual basis? The main things to watch out for are, number one, unstable vital signs. Hypotension, tachycardia, hypoxemia, things like that. You also want to watch out for signs of peritonitis. And so the general signs of that are abdominal rigidity, guarding and rebound, and very intense pain with just very slight pressure on exam.

Liz Rohr:
And then the other thing to think about are just any signs suggestive of worst-case scenario, red flag diagnoses. And this is, again, not comprehensive. But for example, things like ectopic pregnancy, bowel perforations, acute small bowel obstruction, things like that. Mesenteric ischemia, another one, appendicitis, the whole list. So having a general list of what are those worst-case scenario ones and does it seem like it's presenting that way? And number one, potentially getting the assistance of a colleague or making the decision to send them to the ER.

Liz Rohr:
The next general approach that I recommend to kind of help make this a little bit easier, one of the nice things is that now that I have several years of experience, I can go into a room and I have differentials in my mind. And when I'm coming into the room, I'm pulling from those differentials and I'm asking the history questions based on that differential list. But when you're new, there's so much to think about, even if you have those in your mind, it's kind of stressful, right? And so that working backwards way is kind of like the next kind of hack.

Liz Rohr:
So one, is taking the same framework for every single visit. And I feel like I say this all the time, but it is really helpful. So using an OLDCART framework or whatever framework you want, but I use OLDCART. Onset, location, duration, associated factors, relieving factors, and time, characteristics, I think I missed characteristics in there. But using that general approach any single time I have a symptom in front of me, especially if I'm not quite sure what to do, because that will really give you a very pretty good picture to start of what we're looking at.

Liz Rohr:
The next kind of hack of working backwards, especially if you don't have those differentials in the front of your mind, is just doing the full ROS. And I found that I had some ego when I was a new nurse practitioner. I was trying to prove to myself and to my colleagues that I knew what I was doing, and that I was really good at this. But a lot of it, you kind of just have to put your ego aside and just do it for the safe care. The excellent safe care is the most important thing. So for me, I literally brought in a piece of paper with a checklist, like a copy of a checklist of questions to ask because I was so nervous. And you can have that in your EHR, wherever it is, but there's no shame in bringing this into the room because it's all about safe care.

Liz Rohr:
So going through the full ROS for a GI symptom, all of the questions. Nausea, vomiting, diarrhea, constipation, jaundice, et cetera, et cetera, going through that whole list. And then thinking about the associated body systems that are not just GI. Because I think that's one of the intimidating things about abdominal pain, the wide differential diagnosis list, in addition to the fact that presentations are not always textbook. So going into those associated body systems and just asking all those questions, constitutional. Fevers, chills, weight loss, et cetera, et cetera. GU, urinary symptoms, remembering the uterus and ovaries, depending on what organs that person has. What about those systems? What questions do you want to ask? All of them, just ask all of them.

Liz Rohr:
And then cardiac and pulmonary, I think are some sneaky ones sometimes, that we're so focused on abdominal ideologies that we forget sometimes that it's cardiac and pulmonary as well. And again, even if you don't have those diagnoses in the front of your mind, when you ask those full ROS questions, it will help you get there. It'll help you remember to think about that.

Liz Rohr:
And then the next thing has to do with two other kind of like main tip hacks. One is looking at the abdomen in terms of quadrants. So maybe this is not news to you, but actually nine sections. So on the top row, epigastric and right upper quadrant, left over quadrant on both sides, or whatever way that is, I don't know mirroring backwards with the camera, periumbilical in the middle with flanks on either side, suprapubic at the bottom, and left lower quadrant and right lower quadrant. Keeping those in mind when we're talking about the abdominal pain. And again, maybe that's obvious, but I find it really helpful to narrow that down because it helps me understand and remember the organs underneath those quadrants. So if we're talking about suprapubic pain, we're looking at bladder, uterus, ovaries, potentially prostate, ureters, things like that. And you can come up with your differential diagnosis list for each of those quadrants, keeping in mind that you can have referred pain from another quadrant.

Liz Rohr:
For example, cholecystitis, right upper quadrant pain, typically is the classic textbook, which is not always the real world. But you can have that sharp, intense pain in the right upper quadrant. But additionally, you'll also see presentations where it's entire band on the top of the abdomen. So keeping all of that stuff in mind.

Liz Rohr:
I think the last kind of tip, the last general tip that I have about approaching abdominal pain is actually a question that my primary care asked me. I had severe epigastric pain when I was a brand-new nurse practitioner. Turns out it was stress-related, despite all of the workup and the treatments and the blah, blah, blah. Anyway, that is neither here nor there. But the question that she asked me was, "What does it look like in your daily life?" And I thought she was just being like a holistic and really sweet, which she is. She's a wonderful clinician, so, so special.

Liz Rohr:
And she was, but also, I think one of the important things that I missed the full picture of when I was a new grad, it's easy to go in and say, "You know what? You have epigastric pain. Here's the differential diagnoses," ask a couple of questions. I'm like, "Okay, I'm just going to jump right into the lab tests and potentially some imaging." And I want to stress to you that the more detailed history that you can get, the more quickly you will get your diagnosis, it will be a lot more clear, and then you'll get your treatment sooner, and the patient's relief sooner.

Liz Rohr:
So this question of like, it doesn't have to specifically only be that question, but the gist I'm trying to get at with you is can you picture it in your mind? Because it's easy to go from, "Oh my gosh, epigastric abdominal pain. Here's the workup that I need to do," versus, "Okay, do you wake up with it? Do you go to bed with it? Is it on the weekends? Is it the weekdays? How long does it last for?" I mean, you ask those OLDCART questions, but can you visualize in your mind what this looks like? And I actually find that patients have a hard time describing that sometimes. So I think it goes one of two ways. Some people are kind of surprised by it and they have to think about it and then other people are like, "This. Yes."

Liz Rohr:
And I think that kind of like one point to add on is that I think a lot of the times new grads really worry about missing something large because they forgot to ask about something small or didn't notice something small. And things happen. Anything is possible. But the vast majority of the time when you have more serious ideologies, they're going to present seriously, if that makes sense. So, yeah.

Liz Rohr:
So if I can leave you with that. Hopefully that is helpful. Next week, I'm actually going to be talking about a red flag diagnosis, pancreatitis, and how to evaluate that, including the lab. So definitely stay tuned for that. Please let me know what questions you have. If you haven't grabbed the Ultimate Resource Guide for the New NP, head over to realworldnp.com/guide. You'll also get these videos straight to your inbox every week with notes from me, patient stories, and other bonuses that I really just don't share anywhere else. Thank you so very much for watching, hang in there, and I'll see you soon.