 |
|
 |
 |
| |
|
|
| |
| The Acute Abdomen III: Information for Physician Assistants and Nurse Practitioners |
 |
by Bob Blumm, MA, PA-C, DFAAPA - August 26, 2010
|
One of the defining roles of a PA or NP is the ability and thoroughness of their H&P. A complete H&P is essential in making a diagnosis of the acute abdomen and a decision about the disposition—does this patient go to the OR or not? Let’s look at the PQRST to seek guidance on our questioning of the patient and discover whether these letters are more than part of the alphabet.
P- Precipitating or Palliative- Upon asking what causes the pain to be worse or what initiates the pain, we may hear factors that might include change in position, hitting a bump when in the car, pain upon walking or jumping or comments in relation to an association with food or pain that has awakened the patient from sleep. The palliative aspect relates to what improves the discomfort or makes it disappear. Does the patient feel better when they are lying still or after they have eaten something? These are all helpful hints that help to distinguish from peritonitis or a gastric ulcer. So ultimately we are trying to ascertain what makes it better or what makes it worse.
Q- Quality-When seeking a response relating to the quality of the pain it is important to listen to the patient’s description. There is an art to listening that distinguishes it from just hearing. When a patient describes a perforated ulcer they utilize phrases or words such as a sudden, acute, sharp pain. They may describe the pain of diverticulitis as gradual pain in the LLQ (left lower quadrant) that is dull but somewhat continuous and will be able to approximate the length of time the pain has existed and may be aware of a food type that was consumed before the pain started.
R- Radiates- Pain will initially start at a certain location but careful listening will result in the patient describing how the pain seems to have changed locations and is felt in one or more places. Biliary pain radiates to the epigastrium, right shoulder or scapula. Splenic rupture and left lower lobe pneumonia may radiate to the left shoulder (Kehr’s sign.) Small bowel pain may radiate to the epigastrium or to the Periumbilical region whereas large bowel pain may be more significant and radiate to the suprapubic area. Kidney pain may radiate from the flank to the groin, testicle or labia majora. Pancreatic pain will radiate to the upper back, the epigastrium or the left shoulder.
S- Severity- The description of severity can be quite easy or as complicated as the examiner wants to make it. Why use a phrase like on a 1-10 when we can cause a more accurate response by asking on a 1-5. We also have as an aid a tool called the Wong-Baker chart that starts with a smile and concludes with a frown and demonstrates everything between. The patient may also use words such as sharp, stabbing, burning, dull or cramping.
T- Timing- The question that may be used when trying to ascertain the timing may follow along the lines of asking if the pain comes and goes (colicky) or if it is constant. Colicky pain mat be associated with biliary colic, renal colic, bowel obstruction or mesenteric ischemia.
Associated Symptoms- As the history continues, the astute NP or PA should question the patient concerning anorexia, nausea and vomiting, fever and chills, weight loss, flatus and food intolerance. Cholelithiasis has accompanying fatty intolerance. I recently saw a TV spot on the Texas State Fair where the reporter described the number of fatty fried foods such as fried chicken, fried potatoes, fried corn dogs, fried peppers and fried butter to name just a few. Does the patient have cardiac symptoms such as syncope, shortness of breath, chest pressure or palpitations and light headedness? Are there any pulmonary symptoms such as SOB, coughing or coughing up blood, phlegm, wheezing or stridor? Has there been a change in bowel habits, from constipation to diarrhea, hematochezia, and melana or stool caliber. Does the bowel movement look similar to a NATO round or a pellet or is it just plain fluid? What color or consistency is the stool, such as black and tarry versus brown, yellow, gray or bloody? Finally the patient should be questioned for GU symptoms such as dysuria, hematuria, frequency, urgency or burning upon urination.
This is just the start of the direct process relating to their chief complaint. The next installment of this series will relate to the ROS.
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.
RECOMMEND THIS ARTICLE
You must be logged in
to recommend articles
|
|
|
|
| |
|
|
 |
 |
|
 |
 |
 |
|
