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Abdominal Pain Part II Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e- module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT Abdominal pain is one of the most common complaints that patients make to medical professionals, and it has a wide array of causes, ranging from very simple to complex. Although many cases of abdominal pain turn out to be minor constipation or gastroenteritis, there are more serious causes that need to be ruled out. An accurate patient medical history, family medical history, laboratory work and imaging are important to make an accurate diagnosis. Initial assessment and diagnostic testing will provide an early indication of cause and the possible treatment options, which are discussed. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 4 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Health professionals in acute and non-acute health settings need to be able to recognize overt and subtle signs of conditions associated with abdominal pain in order to properly treat and/or refer to a specialist. Course Purpose To provide nurses with knowledge of the causes and treatments of acute and chronic abdominal pain. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. The most common locations of referred abdominal pain include a. face, wrist, elbows, hands. b. back, shoulders, chest, groin. c. internal organs only. d. skin or peripheral areas only. 2. Pain referred to the chest is commonly caused by a. gallstones. b. bowel obstruction. c. gastroesophageal reflux disease. d. None of the above 3. True or False: The clinician should base a diagnosis of abdominal pain solely on the region of associated pain. a. True b. False 4. In a study published in the Journal of Clinical Nursing, nursing perceptions of barriers to adequately control a patient’s pain included: a. Lack of clinical guidelines. b. Lack of standard assessment tool for pain management. c. Limited autonomy when making decisions about pain control. d. All of the above 5. Recurrent abdominal pain is a. mild, nagging pain with no resolution. b. chronic, intermittent pain with separate episodes within 3-months. c. more often seen among children. d. Answers b., and c., above nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction A complicating dynamic in the diagnostic workup of a patient with abdominal pain is the varied typical or atypical pain symptoms and the wide range of conditions that could occur in a clinical scenario. As mentioned in Abdominal Pain Part I, the assessment of pain in the abdomen can be a challenge to diagnose. A thorough patient history is necessary to help isolate potential cause and to identify correct treatment. Additionally, the physical assessment of the abdomen and corresponding diagnostic tests must involve a systematic, standard approach to foster a correct diagnosis of the cause of abdominal pain. Abdominal Pain And Anatomical Location While abdominal pain is often broken down into anatomical location, it is important to recognize that often pain in the abdomen may result from an obscure cause, which can complicate diagnosis. Pain may also be referred from the site of origin. The following section covers some of the types of pain and correlating acute or chronic disease conditions. Referred Pain Referred pain is felt in a site other than the original location of injury or pathology. By understanding common sites of referred pain, the clinician may be able to quickly isolate the underlying cause of the pain the patient is having, both within the abdomen and at a distant site. The patient may have abdominal pain that is also referred to other parts of the body; and, the original abdominal pain may or may not still be present. Often, sites where pain is referred are innervated along the same pathways as the abdominal pain.1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 Referred pain may make the abdominal assessment more complex. Abdominal pain is still usually present, and the initial pain may have worsened in intensity to the point that the pain radiates to other locations. When pain is present in both the abdomen and a referred location, it can be difficult to pinpoint the exact cause, what makes the pain worse or relieves it, and how long the type of pain has been present. Some of the most common locations of referred abdominal pain include to the back, shoulders, chest, or groin. Back Pain A number of painful conditions in the abdomen can cause referred pain in the back. Pain that originates in the pancreas, liver, gall bladder, abdominal aorta, stomach, and kidneys may all cause discomfort that is felt not only in or near these structures, but also in areas of the back. Affected organs such as the liver, gall bladder, and stomach will typically cause referred pain in the center of the back; whereas, the kidneys tend to radiate pain to the lower back. Fortunately, referred pain tends to radiate to the same locations in most people. For example, individual patients who present with gall bladder pain will tend to have similar type referred pain to the center of the back. The healthcare provider should learn and understand the common areas of referred pain so that he or she can quickly recognize referred pain locations associated with abdominal organ dysfunction. Pain with abdominal organs that refer to the back can often be intense and severe, particularly when associated with damage from ischemic pain or a significant inflammatory condition, such as severe pancreatitis. The pain may begin in the abdomen. As the pain intensifies, nerve sensors carry the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 pain to the back. In some cases, the pain in the back may be just as much or more severe than the pain in the abdomen. Shoulder Pain Pain that develops in the shoulders and that is not explained by other events, such as an injury or disease process, may be considered referred shoulder pain when it coincides with symptoms of abdominal pain. Pain in the shoulders and scapula areas can be referred from one or more locations in the abdomen. An abscess in the abdomen may radiate pain to the shoulder, and pain from any condition that causes irritation to the diaphragm may also radiate to this area. Pain associated with the gall bladder, such as gallstones or pain in the bile duct leading to the small intestine often radiates to the shoulder or scapula, in addition to referring to the back.37 Visceral pain associated with the gall bladder may be referred to the shoulder because the pain messages travel along a shared dermatome, which is an area of skin that receives sensation from the same spinal nerve.36 Kehr’s sign refers to a condition in which a patient is suffering from pain in the shoulder area when the injury is in the abdomen. A German surgeon, Hans Kehr, first described Kehr’s sign after seeing a patient with severe clavicle pain due to a splenic abscess. The condition is defined as pain in the area above the clavicle as a result of irritation of the diaphragm. The phrenic nerve that stretches between the diaphragm and the neck carries the pain signal from the area of abdominal injury up to the clavicle and shoulder.82 Patients who have undergone surgical procedures, such as a laparoscopy, may develop shoulder pain. The pain is referred from the abdominal area nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 from the use of air through a surgical instrument to inflate the abdomen during the procedure.
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