Family Medicine 20 Discussion 4

This week, complete the Aquifer case titled Family Medicine 20: 28-year-old female with abdominal pain.

After completing your Aquifer Case Study, answer the following questions using the latest evidenced based guidelines:

• Discuss the questions that would be important to include when interviewing a patient with this issue.

• Describe the clinical findings that may be present in a patient with this issue.

• Are there any diagnostic studies that should be ordered on this patient? Why?

• List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.

• Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.

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You are working in Dr. Nayar’s family medicine office. He informs you, “The next patient on the schedule is Ms. Amanda Bell. She is a 28-year-old, cisgender, female here with a chief concern of lower abdominal pain of a few weeks’ duration. I’m going to have you go take her history and start her physical exam. Before you see her, let’s take a moment to think about the questions you will want to ask her. How would you approach someone with a chief concern of abdominal or pelvic pain?”

TEACHING POINT

Significance of the Location of Lower Abdominal Pain

The location of the abdominal pain is important, as it can help narrow your differential diagnosis. For example, diffuse abdominal pain may represent gastroenteritis, whereas localized right lower quadrant pain is classic for but not limited to appendicitis. Think about what is in the various quadrants of the abdomen when considering the differential diagnosis of abdominal pain. Family Medicine 20 Discussion 4

There are many signs and symptoms of a life-threatening condition in a patient with abdominal or pelvic pain. Examples include:

· Abrupt onset of severe pain

· Shock with hypotension and tachycardia

· Distension

· Peritoneal irritation signs

· Rigid abdomen

· Pulsatile abdominal mass

· Absent bowel sounds

· Fever

· Vomiting

· Diarrhea

· Weight loss

· Menstrual changes

· Trauma, prior surgeries, or operative scars

· History/presence of blood in emesis

· History/presence of blood in stool

· Severity of the pain

· Ecchymoses/bruising

· Rebound tenderness

· Mass or ascites

Dr. Nayar suggests, “Before you go and meet Ms. Bell, let us take a look at her chart in the electronic medical record (EMR) together.”

Because you are aware of the importance of a patient’s surgical history in the evaluation of abdominal pain, you review her chart for prior surgeries and find that her only past surgeries were a tonsillectomy and adenoidectomy at age 17.

You investigate the chart further and find that Ms. Bell is “G1P1001.” Her pregnancy was four years ago, and Dr. Nayar had performed the vaginal delivery of a full term male infant without complications. Family Medicine 20 Discussion 4

TEACHING POINT

Obstetrical History
G

Gravida or number of pregnancies

T

Number of Term pregnancies

P

Number of Preterm infants

A

Number of spontaneous or induced Abortions

L

Number of Living children

You also note that Ms. Bell has not been seen in your clinic for over four years. She was last seen for her postpartum check, at which time she was found to have an abnormal Papanicolaou (Pap) test.

When you mention this to Dr. Nayar, he sighs and explains, “Follow-up of an abnormal Pap test is important because it may prevent later progression to cervical cancer. The early stages of this disease are very treatable. Thus, it is important for the practitioner to document that every effort that has been made to follow-up on an abnormal Pap test. The patient’s chart shows that efforts were made to contact Ms. Bell but that she did not follow through on further evaluation of her abnormal Pap test. We don’t know why she didn’t come back; it could be one of many reasons. Perhaps she moved and did not receive our letters; maybe her insurance changed or ended; life may have gotten too busy with a new baby; maybe she didn’t understand the importance of following up on an abnormal Pap; or maybe it was just plain fear. I would not like to think that she was just not interested.”

Sure enough, despite Dr. Nayar’s notation in the chart of the need for a follow-up appointment, there is no record of a repeat Pap in Ms. Bell’s chart. There are, however, multiple entries documenting Dr. Nayar’s repeated attempts to schedule follow-up care via letters, phone calls and even certified mail.

He tells you, “Documentation is very important; if something is not documented, it did not happen. In Ms. Bell’s case, I noted each time I attempted to contact her. I placed a copy of the lab result letter that was sent to her, in her chart. If her mail had been returned to the clinic, we would have placed that envelope in her chart, too. If you are at all concerned about a patient receiving an important lab result, it is best to send that result by certified mail, if you cannot get them in for a follow-up visit.”

When you and Dr. Nayar have finished your review of the patient’s chart, you go in to see Ms. Bell, with the instructions to return to Dr. Nayar with a report of her history and physical exam.

TEACHING POINT

Documenting Follow-Up and Lab Reporting
Documentation of attempts to schedule follow-up visits and inform patients of laboratory results is very important. Failure to reach a patient by phone or mail should also be documented. If a provider is unable to reach a patient about an important test result (e.g. an abnormal Pap smear), reaching out to emergency contacts and sending a certified letter should be done to document every effort to reach a patient.

You introduce yourself to Ms. Bell and her 4-year-old son, Cooper, who is accompanying her. Cooper is seated on Ms. Bell’s lap and is trying to hide his face in his mom’s jacket. Both the patient and son are neatly dressed, well nourished, and in no apparent physical distress. Family Medicine 20 Discussion 4

You begin to take a history of the present illness:

“The nurse has written in your chart that you have been having some pain in your lower abdomen. Can you tell me more about this?”

Ms. Bell states, “Yes, the pain started to get pretty bad about two weeks ago. I have probably been having pain for the past month or so, off and on. The pains feel sore, achy, and crampy. Anyway, I missed some days at work because of these pains, whatever they are, and now I need a work slip in order to go back.”

“Does the pain seem to stay in the lower part of your abdomen, or does it move anywhere else?”

“No, it seems to stay in the lower part.”

“How bad would you say your pain is, on a scale of 1–10, with 10 being the worst pain you can imagine?”

She answers, “It’s usually about 3 out of 10. But it can be worse, maybe up to a 5, but when it gets that bad it only lasts for a few seconds.”

“What makes the pain better or worse?”

“Being still helps.

But the pain can just come and go on its own. Moving around, like walking or exercise, seems to make the pain worse. I can’t seem to make sense of it all. Sometimes when my husband and I have relations, you know, sex, or even when I just do mild exercise, the lower part hurts. Maybe it’s just sore muscles from my starting back with trying to exercise.”

“Does the pain come at any particular time of day?”

“No, not really.”

“Do you get the pain during the night? Does it wake you up from sleep or prevent you from going to sleep?”

“No. I sleep okay most of the time. My son occasionally wakes up at night with bad dreams, so I get up with him for a while, but I don’t think the pain wakes me up.”

“Did anything happen a month ago when these pains started?”

“No, not really, although I have been under some extra stress, I guess, but that has been for longer than a month.”

A picture containing graphical user interface Description automatically generated

Pain scale

When you ask her about associated symptoms, she notes occasional nausea, vomiting, loose stools, and constipation. She adds that the changes in her bowel movements come and go; between times, her bowel movements are normal. Upon further questioning, she tells you that her stools are a normal brown color, not bloody or black. She also informs you that she had a mild temperature elevation about a week and a half ago. She did not know what caused that.

She has medicated the abdominal pain with two 200 mg tablets of over-the-counter ibuprofen a few times over the past couple of weeks but, “They really didn’t do anything much for the pain.” She reports not taking any regular medications, vitamins, or supplements. She’s never had an allergic reaction to any medicines. Family Medicine 20 Discussion 4

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