RUQ Abdominal Pain Treatment

A 50 yo woman presents with a 6-month history of intermittent RUQ abdominal pain, bloating and nausea, particularly after eating fatty food, describing the discomfort as sharp, occasionally radiating to the right shoulder, usually lasting around 45 mins,  and accompanied by eructation.  She is currently without distress, stating that, “I cut back on food that I know bothers my stomach.  Physical exam reveals, BMI=35, no jaundice, mild RUQ abdominal tenderness and negative Murphy’s sign.  

Which of the following is the next step in her care?  

A. Provide a 1-month trial of proton pump inhibitor (PPI) therapy.

B. Refer to surgery for further evaluation.  

C. Order a RUQ ab for abdominal ultrasound and hepatic enzymes.

D. Obtain serum H. pylori testing.  

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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Doctor Margaret Fitzgerald shares her knowledge and experience to help you 

dissect the anatomy of a test question, so you can better understand 

how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 50-year-old woman presents with a 6-month history of intermittent right upper quadrant abdominal pain, bloating and nausea, particularly after eating fatty foods. 

Describing the discomfort as sharp, occasionally radiating to the right 

shoulder and lasting about 45 minutes, and is accompanied by eructation. 

She's currently without distress, stating, “I've cut back on the food that I know bothers my stomach.” 

Physical exam reveals the following: BMI 35, no jaundice, mild right upper quadrant abdominal tenderness and negative Murphy sign. 

Which of the following is the next step in her care? 

A: Provide a 1-month trial of a proton pump inhibitor (PPI) therapy. 

B: Refer to surgery for further evaluation. 

C: Order a right upper quadrant abdominal ultrasound and hepatic enzymes. 

D: Obtain serum H. pylori testing. 

The correct answer is C: Order a right upper quadrant abdominal ultrasound and hepatic enzymes. Where should you start? 

First, determine what kind of a question this is. Given that you're already thinking that you need to figure out what's causing the patient's discomfort-this is actually an assessment question where you need to gather more information. 

I'm going to approach this question a little bit differently than I do 

in many other questions in the podcast, because this question is one 

where you need to carefully analyze and synthesize all the data presented in clinical practice. 

This is what we need to do. Let's hop right into the question. 

A 50-year-old woman presents with a 6-month history of intermittent 

right upper quadrant abdominal pain, bloating with nausea, particularly 

after eating fatty food, describing the discomfort as short, sharp, occasionally radiating to the right shoulder and usually lasting 45 minutes, and is accompanied by eructation. 

She's currently without distress, stating, “I cut back on the food that I know bothers my stomach.” Physical exam reveals a BMI of 35, no jaundice, mild right upper quadrant abdominal tenderness, and negative Murphy sign. 

Which of the following is the next step in her care? 

A: Provide a 1-month trial of PPI therapy for proton pump inhibitor therapy. 

Choosing this implies that you've been able to make the clinical diagnosis without additional testing needed. 

Of course, with GERD, the diagnosis is made clinically based on the patient's history, physical exam, and presenting signs and symptoms 

without requiring laboratory testing or imaging. 

And with GERD therapy, often one way of approaching it is to make the diagnosis clinically, then treat it and see what response is. 

However, she's not reporting GERD signs and symptoms, which would likely 

include dyspepsia or heartburn, eructation, and postprandial fullness. 

Now, I will grant you one thing that sounds GERD like is that she has figured out what foods bother her stomach and has cut back on them. 

As I mentioned, PPI therapy is recommended first-line in the treatment of GERD and further evaluation, including upper endoscopy, is recommended 

when first-line therapy fails and/or when there are other findings. 

I'll cover GERD in another podcast. 

B: Refer to surgery for further evaluation. This is an answer that appears to be at least partially correct. 

You may have read through the case and thought, okay, this person is presenting with what appears to be gallbladder disease and would likely benefit from referral but have you confirmed that diagnosis? 

Not yet. This answer then would be a planned intervention question. And you're really still in the assessment information gathering state. 

C: Order right upper quadrant abdominal ultrasound and hepatic enzymes. 

This is of course the correct answer, as this will help confirm ruling or rule out the working diagnosis of gallbladder disease, usually caused by gallstones. Many patients with gallstones have intermittent discomfort 

as a result of this condition. 

The pain is described as a sudden onset, usually postprandial, 

Particularly within 1 hour of a fatty meal in the abdominal right 

upper quadrant or epigastric area occasionally radiating to the tip of the right scapula which is known as Collins' sign, or as or just any right upper quadrant radiation where it can go up even to the shoulder. 

Episodes of discomfort typically last about a little bit less than an hour to up to 5 hours, with patterns of increasing then decreasing discomfort as the gallbladder contracts and the stone position shifts. 

Nausea and vomiting are quite common during painful episodes. With cholecystitis, where the gall bladder is inflamed, the patient will stop breathing in with the deep right upper quadrant abdominal palpation. 

And that's what's known as a positive Murphy's sign. Common risk factors for gallstone formation include age over 50, female birth sex assignment, and obesity. 

And this patient ticks off all three of those boxes. 

And by the way, once you have confirmed the fact that there are gallstones and very often the hepatic enzymes are bumped up a little bit, they're not sky high, but they're bumped up a little bit very often. 

The next step is referral to surgery. 

So why wouldn't referral to surgery be a better answer? Because what are the NP boards wanting to see in you? 

They want to see you make the diagnosis before you do the surgical referral. So this is a good example of two perhaps technically correct answers, but one is the better answer. 

Okay. Option D: Obtain serum H. pylori testing. 

This is incorrect. Infection with H. pylori is a risk factor for the development of peptic ulcer disease, also known as PUD. 

This patient's clinical presentation is not consistent with that diagnosis, where typically the patient reports a burning sensation, gnawing hunger or hunger or pain in the epigastric arm that is relieved with eating. 

In addition, and this is important, don't order H. pylori. Even if you're thinking peptic ulcer disease, it's not the preferred diagnostic testing. 

And I will cover testing in peptic ulcer disease and another podcast. 

But you do need different diagnostic modalities. Key takeaway: being able to clarify the reason for the NP board question answer-whether the question is a focused on assessment, diagnosis, plan/intervention or evaluation is key to clinical and NP board success. 

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