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Differential Diagnosis for Abdominal Pain & Documentation Pearls

Blog_AbdPainDocumentationPearls_AbdPainExamManYoung_260x200px.jpgPatients with abdominal pain are a common and constant challenge to practitioners in primary care, pediatrics, urgent care, and emergency medicine. The complaint of “stomach and abdominal pain” comprised 7.7% of ED visits in 2013. The clinical presentations may be confusing, the differential diagnoses for abdominal pain are myriad, and not all patients with abdominal pain will have a serious underlying etiology.

Medical errors and litigation involving the care of patients with abdominal pain are all too frequent and can be costly for both patients and physicians. The cornerstone of high-quality, defensible care consists of a systematic approach coupled with compulsive documentation. The essence of liability reduction in the care of patients with abdominal pain is to construct a medical record that provides a thorough, clear and logical explanation for your thoughts and actions. Here are a few key items to address in the chart documentation.

History of Present Illness

  • Location of Pain: Where it started and where is it now
  • Radiation of Pain: To back, groin, chest or elsewhere
  • Timing: Did pain precede vomiting (more common with surgical disease) or did vomiting precede pain (less likely a surgical problem); abrupt or rapid onset vs. crescendo or slow
  • Associated Signs & Symptoms: Anorexia, nausea, vomiting, jaundice, prior indigestion, constipation, diarrhea, blood in emesis or stool, rectal pain, urinary frequency, dysuria, hematuria, dyspnea, cough, fever, chills, syncope, lightheadedness, abnormal vaginal discharge or bleeding
  • Modifying Factors: What helps or hurts, such as movement, coughing, respiration, eating, position, vomiting, antacids or medications

Risk Factors

  • website_author_syzek1-e1446040915762.jpgAAA Risk Factors: Age ≥ 50, male, smoker, COPD, hypertension, hyperlipidemia, diabetes, ASCVD, Marfan or connective tissue disease, 1° relative with AAA
  • Ectopic Pregnancy Risk Factors: PID, IUD, prior ectopic, infertility treatment, abnormal menses
  • Elderly ➞ higher risk for serious causes requiring surgery
  • Past Abdominal Surgery ➞ higher risk for bowel obstruction
  • Alcohol Use ➞ risk for GI bleed, hepatitis, pancreatitis, gastritis, and PUD
  • NSAID or Steroid Use ➞ risk for PUD, perforation
  • Asplenia or Immunosuppression ➞ risk for infections and atypical presentations of serious illnesses

Physical Exam

  • Abdominal Exam: Appearance, distention, bruits, bowel sounds, organomegaly, tenderness, guarding, rebound, rigidity, and presence or absence of pulsatile mass
  • Genital: Males – check for hernia, testicular swelling, mass or tenderness; Females – pelvic exam for discharge, cervical motion tenderness, adnexal masses or tenderness, bleeding, tissue or lesions
  • Rectal: Stool hemoccult positive or negative
  • Extremities: Color (blue toes), edema, pulses present or absent in legs, tenderness, temperature, emboli from AAA

Course in the Office, Clinic, Urgent Care or ED

  • Document serial abdominal exams if patient’s evaluation lasts several hours.
  • Record the results of treatment and medications given.

Medical Decision-Making

  • Address the results of all tests ordered.
  • Document a differential diagnosis and discuss your reasoning regarding the likelihood (or not) of serious causes, including AAA, appendicitis, biliary tract disease, bowel obstruction, diverticulitis, ectopic pregnancy, mesenteric ischemia, MI, ovarian torsion, pancreatitis, PID, pyelonephritis, renal stone, testicular torsion.

Plan

  • For Admitted Patients: Record who was consulted and when, and specify clearly whether you request surgical consultation and how soon.
  • For Discharged Patients: Include time-specific (e.g., within 6 to 24 hours), and person-specific (e.g., PCP, specialist) discharge instructions.
  • Provide clear instructions that include specific reasons to return (e.g., any return of pain, worsening of pain, change in character or pain, fever, vomiting, bleeding, inability to keep P.O. fluids down).

CAVEAT!

Most medical errors and litigation related to abdominal pain occur with patients who are discharged rather than admitted. Along with clear, time- and person-specific discharge instructions, the most important tool for providing good care and reducing liability is plain and simple communication with patients and their families. Tell them what you are thinking, who to see next and when, for what reasons to return to the ED, and that THEY ARE WELCOME TO RETURN ANY TIME THEIR CONDITION IS WORSE.

Our courses cover the following topics in extensive detail:

avoidable-admissions

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Categories: Emergency Medicine, Urgent Care

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