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| The Acute Abdomen- Part ll: Information for Physician Assistants and Nurse Practitioners |
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by Bob Blumm, MA, PA-C, DFAAPA - August 19, 2010
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I have spoken with my favorite editor, Mike Gerchufsky, and it would take an extended period of time to have this published in their journal, so I was encouraged to go ahead with AdvancedPracticeJobs.com. This will be the second of perhaps eight installments on this subject and will be available as a two hour lecture at any of your state or specialty meetings. I will try to keep this as concise as possible, in the hopes that all may learn and that we as advanced practice clinicians continue to improve or service and commitment to our patients.
Perhaps one of the big questions that we face as clinicians is, “Can we improve our diagnostic skills?” Most would rapidly say, “Of course!” When we speak of the “Acute Abdomen” we are speaking of one of the top three reasons that patients visit the emergency department or the urgent care center. Ask anyone in a room of people if they have ever had a severe pain in their abdomen and you will discover that 100% have encountered this problem. One of the amazing discoveries is that 40% of patients are discharged from the ER with a diagnosis of “Unknown etiology.” 60% of patients are discharged from the ER with the wrong diagnosis. An article in Emergency Medicine Journal stated that on an average adult patient, the correct diagnosis was made 60% of the time; on pediatric patients, 40-50% of the time; on geriatric patients over the age of eighty, 29% of the time. The older the patient, the broader the differential diagnosis and greater opportunity to miss the diagnosis, which in many of these cases, can be fatal. Fortunately for my 82 y/o mother-in-law, the correct diagnosis was made for her abdominal pain and after testing she was prepared for a laparoscopic Cholecystectomy which was performed in Charleston, SC in a record 10 minutes. It pays to be a ninety pounder as this would certainly have been a much longer procedure with me. Looking at these figures I believe that it demonstrates that there is a large room for improvement.
The Acute Abdomen has, as a hallmark, the presence of pain. That pain can be referred pain, somatic pain or visceral pain. A great example of referred pain would be Kehr’s sign---diaphragmatic pain from blood or pus under the diaphragm which produces pain on the top of the shoulder. Somatic pain stems from an irritation of the innermost parietal surface and is transmitted through the segmental spinal nerves. Visceral pain is due to distention of a hollow viscus and transmits through the sympathetic, parasympathetic or somatic pathways. Regardless of the presentation, this information can only be elicited from the clinician who is expert in obtaining a good history. A good history requires asking the proper questions without leading the patient and then listening, not just hearing, but carefully allowing the patient to explain, in their own words, the pain that they are experiencing. This listening is a skill that becomes reproducible after many patient encounters and can always improve. Our next article, The Acute Abdomen- Part lll, will deal with the physical 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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| Bob Blumm (Amityville, NY) |
on 24 Aug 2010 at 8:52 pm |
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Happy that you found the article interesting and that you have the concern that is neccessary for a clinician in the care of their patients. Have a great career as you are needed.
Bob |
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| Anonymous |
on 24 Aug 2010 at 7:36 pm |
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| I liked this. I work with older adults and usually get the patient back with the same problem they were sent out. Constipation and diverticulosis seem to be the most common cultprit. But I had a non-verbal older man with severe dementia have overt rebound tenderness(undiagnosed perforation) and only a 99 temperature was recorded for this toxic gentleman. Luckily the rebound tenderness (grimacing and startle upon palpation) got him a KUB and OR and recovery. |
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