Introduction
Features of pain are helpful hints for accurate diagnoses. Consequently, terminologies such as acute, recurrent, chronic, and tender are useful in describing the pain. Precipitating and aggravating factors, location and duration of the pain in addition to other symptoms are also vital during diagnosis (Dains, Baumann, & Scheibel, 2012). The nurse practitioner (NP) should conduct a physical examination and additional diagnostic tests for affirmative diagnosis in patients with gastrointestinal pain.
Physical Examination and Appropriate Diagnostic Tests
Abdominal physical examination techniques involve inspection, auscultation, percussion, and palpation. First, the NP observes the skin for scars while noting skin color discrepancies like striae and stretch marks (Ball, Dains, Flynn, Solomon, & Stewart, 2014). Such marks help in identifying whether a previous surgery is the cause of pain. The NP observes the abdominal shape for general or local distention and engorgement of veins to exclude internal organomegaly.
Abdominal inspection of intra-abdominal organs for abnormalities like swellings then follows. Most masses are due to hernias, tumors and hematomas. The location of the mass with respect to adjacent organs helps determine the origin of the swelling (LeBlond, Brown & DeGowin, 2014) and helps in identifying the underlying condition. Auscultation establishes the presence of bowel sounds. The NP auscultates with the diaphragm of the stethoscope for bruit sounds over main arteries during heart contraction particularly over the abdominal aorta, renal artery and iliac artery. In certain instances, the nurse practitioner can hear abdominal rubs or feel an abdominal mass on auscultation above the liver. Auscultation reveals gastrointestinal motions such as peristalsis and helps in ruling out intestinal obstructions (Glynn & Drake, 2012).
During percussion, the NP uses the mid finger of the right hand. Pain on percussion suggests inflammation, and the two key sounds to note during the procedure are tympanic and dull sounds. Dull sounds indicate the presence of fluids and help in ruling out conditions such as ascites. The last step is palpation, which starts in the right upper quadrant and can be either deep or superficial. Deep palpation is useful in assessing the mass because it reveals tenderness, spasms and guarding. Guarding spreads throughout the whole abdomen, while rigidity affects the swollen area only. Palpation is useful in revealing conditions such as fecal impaction.
The diagnostic tests that the nurse practitioner conducts include white blood cell count to determine inflammation. Liver and pancreatic enzyme tests help determine specific organ involvement. Imaging studies like X-rays, ultrasound and computed tomography are also important to observe the affected organ. Manometric tests help in measuring pressure in the gastrointestinal tract while endoscopy facilitates the visualization of internal organs and tumors (Porter & Kaplan, 2011).
Five Differential Conditions for the Patient’s Differential Diagnosis
The following differential diagnoses are possible because all of them present the symptoms that the patient exhibits. The first condition is incarcerated hiatus hernia, which is likely in males above 50 years. Pain may be due to passing of gastric contents into the hernia causing nerve compression when lying down. The second differential diagnosis is peptic ulcers specifically ulcer ventriculi, which has symptoms that worsen with food intake. The third possible condition is bulbi duodeni because of the abdominal pain. However, the diagnosis rules out this condition because food intake relieves pain in bulbi duodeni ulcers (Porter & Kaplan, 2011).
The fourth possible condition is pancreatitis, a common abdominal condition in older adults. Pancreatitis presents with pain symptoms that are similar to those shown by the patient. Additionally, symptoms such as nausea, vomiting, dehydration and signs of inflammation also accompany pancreatitis and can help in deciding whether pancreatitis is the affirmative diagnosis. The fifth possible condition is gastro-esophageal reflux disease (GERD), which presents with painful sensation or distress after eating when the patient lies down or leans forward (Porter & Kaplan, 2011).
Conclusion
Comprehensive physical examination reveals key areas of suspicion in abdominal pain due to multiple organ involvements. Conducting thorough differential diagnoses, therefore, helps identify the actual condition, hence enabling proper management.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2014). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Web.
Dains, J., Baumann, L., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care (4th ed.). St. Louis, MO: Elsevier Mosby. Web.
Glynn, M. & Drake, W. (2012). Hutchison’s clinical methods (23rd ed.). St. Louis, MO: Elsevier. Web.
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw-Hill Medical. Web.
Porter, R. S. & Kaplan, J. L. (2011). The Merck manual of diagnosis and therapy (19th ed.). White Station, NJ: Merck Sharp & Dohme Corp. Web.