by Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC
The NP certification examinations are tests of the broad knowledge base required for nurse practitioner practice. Included in this knowledge base is a set of highly developed clinical assessment skills that encompass history taking and physical assessment. Clinical assessment expertise is critical to arriving at the correct diagnosis.
When seeing a patient with an acute health problem, a health history that includes careful documentation of the presenting signs and symptoms is vital as a guide for the physical examination. The results of these two important clinical findings are the basis for developing a working diagnosis. Based on the findings of the clinical assessment, you can focus the diagnostic work-up. This is a skill that will be thoroughly tested when answering questions on the NP certification examination – quite a challenging task when the scenario is presented as a test question rather than as a live patient. Here is an example:
A 45-year-old man with a seizure disorder that is well controlled with valproic acid presents with a 12-hour history of acute onset of mid- to upper-abdominal pain with radiation through to the back. The pain has been constant during this time and he rates it as 8 or 9 on a scale of 0 to 10. He also complains of severe nausea and has vomited five times since the onset of the pain. Physical examination reveals an acutely ill appearing man who rests on his left side with legs drawn up. Abdominal examination reveals slightly hypoactive bowel sounds, a soft, slightly distended hypertympanic abdomen and moderately severe epigastric tenderness without rebound. Murphy’s sign is absent. The most likely diagnosis is acute:
A. renal colic
C. peptic ulcer disease
The correct answer is D.
A few things stand out in this case. First, many of you will read this scenario and beg for more information about the patient. However, in the testing situation, you are limited to the information given. There are many clues to the patient’s most likely problem. Let’s consider each answer choice and determine the best response.
Renal colic – In renal colic, acute urinary tract obstruction by a stone triggers the pain. The pain is typically described as sudden in onset, severe and incapacitating. However, the pain waxes and wanes as the stone’s position changes. The patient is often writhing in pain, not lying quietly on his side as the patient in this situation is. The location of the pain in renal colic depends on the location of the stone. Flank pain suggests a stone in the proximal ureter, whereas pain in the anterior abdomen suggests a stone in the mid-ureter. Pain in the genitalia and suprapubic area suggests a stone in the junction between the ureter and bladder. The upper abdominal pain described in this question is not typically associated with renal colic. While vomiting can accompany the severe pain of renal colic, abdominal examination findings are usually normal.
Acute cholecystitis – This condition is most commonly caused by acute cystic duct obstruction by a stone. Less common but important reasons include gallbladder ischemia or stasis, also known as acalculous cholecystitis and most common in the older adult, or infection, which is most common in the person with HIV or other immunocompromise. Cholecystitis pain usually presents as a persistent, dull ache localized to the right upper quadrant. The report of pain that radiates to the right infrascapular area strongly supports diagnosis. Common associated symptoms include nausea, vomiting and low-grade fever. The report of repeated vomiting, as reported in this case, is rare. The quality and location of the pain also differs from that reported with acute cholecystitis. This, coupled with the absence of Murphy’s sign and the painful arrest of inspiration triggered by palpating the edge of the inflamed gallbladder, makes the diagnosis of cholecystitis less likely.
Peptic ulcer disease – In peptic ulcer disease, the majority of patients report intermittent dyspepsia that is temporarily relieved with food or antacids. On examination, mild epigastric tenderness with an otherwise normal abdominal examination is usually noted. Nausea and vomiting are reported in about 10% to 15% of cases. More severe signs and symptoms, such as those noted in this case, should raise suspicion for complications of peptic ulcer disease. The symptoms in this case are much more severe than those typically associated with peptic ulcer disease. When severe pain and frequent vomiting are present, consider the diagnosis of gastric outlet obstruction. In such a case, the abdomen is likely to be quite distended with altered bowel sounds. If severe abdominal tenderness is present, particularly with peritoneal signs such as rebound tenderness and the presence of obturator and psoas signs, suspect a perforated ulcer. The case as presented lacks these findings, making these diagnoses less likely.
Acute pancreatitis – Most health care providers are aware of the most common risk factors for acute pancreatitis, such as chronic alcohol abuse, gall stones and hyperlipidemia (particularly elevated triglycerides). The use of certain medications such as corticosteroids, valproic acid, estrogen, furosemide and hydrochlorothiazide increase the risk of pancreatitis. The patient in question is taking valproic acid. The three most common symptoms of acute epigastric pathology are periumbilical pain of acute onset (95% of patients) with or without radiation to the back; nausea and vomiting (85%); and low-grade fever. On physical examination, exquisite epigastric or periumbilical tenderness is the rule, usually accompanied by mild abdominal distention and hypoactive bowel sounds. Rebound tenderness is usually absent unless the pancreas has become necrotic. Given the history of valproic acid use coupled with the clinical findings, the best response to this question is option D, acute pancreatitis.
Continue to hone your assessment and diagnostic skills. This will serve you well when you apply these skills as you take the NP certification examination
Fitzgerald, M.A. (2005) Nurse Practitioner Certification Examination and Practice Preparation, 2nd Edition, Philadelphia: F. A. Davis.
Jones T, Sharma P. Merck Medicus. Best Practice of Medicine: Abdominal Pain. 2003. Available online at http://merck.micromedex.com/
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This article originally appeared in my quarterly certification column in Advance for Nurse Practitioners and is made available here by the courtesy of Advance. For other articles of interest to Nurse Practitioners, be sure to subscribe to this outstanding journal.