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| Acute Abdomen- Part lV: Information for Physican Assistants and Nurse Practitioners |
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by Bob Blumm, MA, PA-C, DFAAPA - September 1, 2010
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When we last looked at associated symptoms I touched on a good number of presentations; however, I would continue to add just a few more. Does the patient present with GU problems such as dysuria, hematuria, frequency, urgency or burning? These all contribute to the need of a thorough GU work-up. A sexual history can be extremely illuminating whether the patient is male or female. A good sexual history will require the patient to inform you if they are currently or in the past months, sexually active; if so, were the partners of the same or opposite sex. My friend Tom works in a practice where all of his patients are teenagers with STDs. When asking him if I should be concerned with a current history he informed me that this would be incomplete and that the question should consider life sexual history. Has the patient had one partner (unusual), a few, ten or more, or were they incorporated having hundreds of partners. A recent “Law and Order” episode told the tragic story of a young woman who was captured as a NY runaway, controlled by drugs and a pimp and had 15 or more sexual encounters daily for more than 16 years, six days weekly. Do the mathematics and we can now envision over ten thousand partners.
Other associated problems could be past or present A-Fib or ventricular disturbances. Acute pain that is severe enough can bring on a new A-Fib and can create tachycardias that in some may progress to potentially lethal. This is why an EKG is extremely important in patients over fifty. Medical conditions such as diabetic Ketoacidosis is also notorious for abdominal pain. Of note, is that HIV often involves the gut.
A family and a social history add to the broad spectrum of possibilities. Is there a family history of inflammatory bowel disease, bleeding diathesis, connective tissue diseases, sickle cell anemia, or family trends for colon cancer? Has the patient recently traveled out of the country into third world areas where there may be parasitic infestations? Environmental lead toxicity causes abdominal pain as can a combination of drugs and alcohol.
Gynecologic history- When was the patient’s last menses? Was it early or late? What contraceptive choices has she made? There can be a greater incidence of ectopic pregnancy with an IUD. Other than the previously discussed sexual history the clinician must obtain a obstetrical history which would include the number of pregnancies, miscarriages, abortions, types of delivery whether vaginal or by C-Section, complications, blood loss, anesthetic problems, gestational diabetes or any problems related to the pregnancy. Has the patient had recent vaginal bleeding or discharge? If so, color, amount of bleeding or discharge, was the discharge clear, white, yellow, green or rusty? Was the discharge malodorous? A previous history of STDs will help the clinician to consider PID.
Past Medical History- whereas this is an urgent care or ER visit, it remains necessary to gather focused data that may lead to preventing other problems. Is there a history of cardiac or pulmonary problems? Is there any GI or vascular disease? Is there a history of DM, HIV, AIDS or hepatitis? What medications is the patient presently taking, including prescribed medications, medications share from a friend, OTCs, NSAIDS or herbal supplements? Has the patient recently had any invasive procedures such as endoscopic procedures? Has there been a recent trauma unreported or not seen in a hospital? Has the patient had a recent URI or a strep throat?
The Physical Exam- Although this will be covered in the next installment of this series, it is essential to have a coherent physical exam that includes general appearance, chest, abdominal, rectal, pelvic, testicular and GU, in general. Questions that should be addressed by the clinician are related to the presentation of the patient. Does this patient seem to be in distress? What is the present body position? Is the patient in a knee-chest position or lying supine and very still or are they a constant blur of motion, trying to reposition themselves because of pain. Look at the patients color and discern if they are pale, gray, yellow or flushed. What are the vital signs and remember that they need to be reassessed frequently as they can change rapidly and have a catastrophic outcome. Is the patient acutely ill or chronically ill? Is the patient diaphoretic? Is there evidence of a rash on their body or extremities? All of these findings are of general importance before we initiate the physical exam. Our next article will begin with the thoracic exam.
 Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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