Differential Diagnosis of Abdominal Pain Science Photo Library Photo Science
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nurse practitioners Differential diagnosis of abdominal pain Science Photo Library Photo Science Elizabeth Haidar describes s a trainee advanced nurse practitioner was because the characteristics of SOAPIER how she used nursing (ANP) in general practice, the author is resembled the nursing process, with which frameworks and medical Arequired to use new rules for assessing, the author was familiar, and it complemented models to diagnose a patient diagnosing and treating patients. This involves a the medical model. This is a logical, problem- combination of frameworks, models, strategies oriented model, using medical record charting with abdominal pain and practice skills, and this article outlines how as baseline data and a plan of care (Dains et all these were used recently as part of a patient’s al 1998). While the SOAPIER model could be management process. criticised for being solely problem focused, The patient, a 41-year-old caucasian Ehrenberg et al (1996) state that to obtain a catering assistant who will be called Sue to good understanding of the patient’s situation, protect her identity, presented to the clinic it is necessary to analyse each problem for with abdominal pain. A combination of the nursing relevance as well as the patient’s need. nursing framework and medical model was Andersen (1993), Carpenito-Moyet (2004) applied to the process of consultation in line and Jarvis (2000) concur that the most with the World Health Organization’s (1946) effective way to collect subjective data may statement that health is a complete state of be by winning trust from the patient through physical, mental and social wellbeing and not sharing, caring and respect. In contrast, merely the absence of disease and infirmity. Browse (1997) argues that the practitioner Since the ANP does not just look at should guide the consultation initially. Having the problem but aims to adopt a holistic reflected on the matter, the author felt the approach to health care, it felt logical to former approach to be more effective in use both models to care for the patient. establishing the consultation with Sue. This There are a number of consultation models was achieved by maintaining eye contact and available. Each model has its own merits, for allowing her to talk freely about her problem. example, Neighbour’s (1987) safety netting, Cohen-Cole’s (1991) three functions in the Differential diagnoses medical interview, Kurtz and Silverman’s (1996) Keywords five tasks, and Mead and Bower’s (2000) five Sue complained of sudden abdominal pain after }}Nurse practitioners conceptual dimensions of patient-centredness. eating her evening meal. The author explored }}Consultation the focus and radiation of the pain using open- }}Diagnosis The SOAPIER model ended questions and listening skills (Atkinson }}Patient assessment and Murray 1995). Sue said she also experienced This article has been subject However, the SOAPIER model (Box 1) was right shoulder pain and the author identified her to double blind peer review selected as the framework of choice. This reluctance to mobilise this area. By this stage, 20 primary health care | Vol 19 No 1 | February 2009 the author already had enough information 1999). Her pulse was tachycardic at 90 beats Box 1. SOAPIER model to list some possible diagnoses for Sue’s per minute and her respirations were faster S refers to subjective data, abdominal pain, which included cholecystitis, than expected at 20 breaths per minute. information the patient or appendicitis, ectopic pregnancy, colic pain, Furthermore, Sue’s rapid respirations family member shares with pancreatitis, gastroenteritis, abdominal aortic were typical of autonomic (sympathetic) the ANP about healthcare problems and concerns. aneurysm and small bowel obstruction. responses to pain, which can include raised Sue began to digress from relating her pulse, shallow rapid breathing, pallor and O stands for objective data symptoms so it was at this point that the anxiety (Atkinson and Murray 1995). – factual and measurable author used the medical model to refocus the Sue’s blood pressure was taken to look data gathered during the consultation, attending to an order of questions for signs of hypotension, which would be assessment, such as vital signs, breath sounds, results to elicit a diagnosis (Hinchliff et al 1993). a sign of reduced blood volume, shock, of lab tests, and the patient’s This proved helpful to the consultation cardiac failure and sepsis (Harris 2002). responses to treatments. process, as a disadvantage of the SOAPIER However, Sue was normotensive with model in this context is that it emphasises the a blood pressure of 135/72mmHg. A is the assessment. The chronology of problems rather than their priority. Alongside the objective data, Sue was conclusions about the Using the medical model as a framework experiencing diffuse abdominal and shoulder patient’s problem are based on subjective and objective data. for the consultation, the author elicited pain with inflammation somewhere that They are listed as the individual from Sue that her medical history included was possibly making her nauseous. As a patient’s problems, and are a hysterectomy. She had no allergies result, the author needed to find the source written as nursing diagnoses and was not taking any medications. of the pain using her practical skills. or other problem titles. Enquiries regarding Sue’s social history On inspection the patient was trying to P describes the interventions revealed that she lived with her partner, shallow breathe to avoid any unnecessary planned to resolve the had three children, was a non-smoker pain. Also, auscultation proved the bowel specific problem. and drank seven units of alcohol a week. sounds were reduced, which Jarvis (2000) Her family history included her mother’s advises is a sign of inflammation. I is the implementation hypertension. Sue also stated that there were Again, the author’s intuition was that of that plan. no changes in bowel habits or micturition. this inflammatory process somewhere E is the evaluation of From the information gathered, the author in the stomach was causing Sue to be how effectively the plan had ascertained that Sue was experiencing pyrexic and making her feel nauseous. was put into place. abdominal pain, shoulder pain and had Concurrently, percussion was performed and vomited. She was feeling nauseous but could normal resonance was identified throughout R is the reflection of the whole not relate it to anything she had eaten. each quarter of the abdomen (Turner and process – could it have been more effective in any way? Although Ford and Munro (2000) Blackwood 1991). Also, palpation showed argue that the subjective data is the most generalised abdominal guarding throughout important aspect of clinical assessment, (Farrar 2001, Trowbridge et al 2003). Sue Jamison (1999) warns against using was able to establish the point where the subjective data in isolation since objective pain was located: the upper right quadrant. information is regarded with more respect. For that reason, the author went on to Narrowing down the diagnosis employ the mechanism approach to distinguish any abnormalities. In this approach, the The author used hypothetico-deductive mechanism causing the abnormality gives rise reasoning to differentiate between the various to the symptoms, so for example, if bowel potential diagnoses. This technique is commonly obstruction was the mechanism, the objective used by clinicians and nurse practitioners symptoms would be vomiting and constipation. (Barrows and Feltovich 1987, White et al 1992). Appendicitis was ruled out because the nature Clinical examination and site of the pain, and age of the patient, did not warrant this diagnosis (Ford and Munro The steps of clinical examination were 2000); likewise for pancreatitis. Similarly, the explained to the patient and her consent was nature and site of the pain did not fit with obtained. On examination, Sue appeared gastroenteritis, especially with the referred pain pale and distressed and was pyrexic with a (Sapira 1990) to the right shoulder (pancreatic temperature of 38.9˚C. This was suggestive of pain tends to go through to the back but some form of inflammation as fever is caused to the left, according to Browse 1997). by the release of endogenous pyrogens from Equally, the author ruled out small bowel polymorphs and other white cells (Jamison obstruction because constipation usually primary health care | Vol 19 No 1 | February 2009 21 nurse practitioners accompanies this (Jarvis 2000) and Sue had (cholecystitis) and a possible hospital admission. stated that her bowel habits were normal. Her social situation was explored, identifying The author also ruled out abdominal aortic any problems that might occur during her aneurysm due to the lack of vascular stay in hospital; Sue had full family support. sounds/bruits (Jarvis 2000). Hypothetico- The author encouraged Sue to feed back after deductive reasoning excluded the possibility this event and to keep her updated because, of an ectopic pregnancy because the in primary care, there is no real follow-up patient had undergone a hysterectomy. assessment after a referral of this sort. The The author went on to use the heuristic author welcomed feedback to generate change. strategy. Heuristics, or ‘rules of thumb’, are mental strategies used as short cuts to reduce Conclusion the complex task of assessing diagnostic probabilities to assemble a judgement Sue’s diagnosis of cholecystitis was reached process (Goldman 1990, O’Neill 1995). by using the SOAPIER model and the medical As a result, the author identified the site of model, which gave a balance between subjective the pain, palpating the abdomen while the and objective data. Furthermore, the diagnosis patient gave a deep inspiration with arresting was abstracted through use of communication, pain (Murphy’s sign), a sign indicative of frameworks and models, strategies, practical cholecystitis (Turner and Blackwood 1991, Ford skills, some degree of intuition and experience. and Munro 2000, Potter and Weilitz 2003).