NR511 Faculty Tip Sheet: Week 5-Gastrointestinal

NR511 Faculty Tip Sheet: Week 5-Gastrointestinal
Instructions: this tip sheet accompanies the notes designed for this case located in i-
Human. Use the tip sheet to guide you in scoring the grading rubric and for coaching
your students when they have questions and need guidance for improvement.

Brief Case Summary: Deborah Arnaudin: Small Bowel Obstruction

 Active, progressive abdominal pain for two days, periumbilical discomfort with
diffuse tenderness to palpation

Key Findings Students Must Identify in the Case:

 The medical problem list or list of potential findings the student compiled should
include everything that is out of the ordinary about the client, even when it is not
a problem
 Acute, progressive abdominal pain for 2 days, periumbilical discomfort with
diffuse tenderness to palpation.
 Remind students to keep focused on the MSAP for easier identification of other
case findings that may be related to the MSAP. This will help guide further
history-taking and help students to arrive at the most important differential
diagnoses
 Bilious emesis (related to MSAP)
 High cholesterol (related to MSAP)
 Prior abdominal surgeries 1+ year ago (related to MSAP)
 Heavy alcohol use (related to MSAP)
 Tachycardia (related to MSAP)
 Lack of fever (relatd to MSAP)
 Absent bowel sounds, bowel movement, flatus (related to MSAP)
 Abdominal distention and tympany (unknown if related to MSAP)
 Because the patient does not have a prior chart:
o Additional PMH
o Additonanl SH
o Medications/Allergies
o ROS
o Communication

Coaching students if they have questions about the key findings:

 Remember that key findings should include everything that is out of the ordinary
about this client, even when it does not appear to be a “problem”.
 For this client, the Most Significant Active Problem (MSAP) is acute, progressive
abdominal pain for 2 days with periumbilical discomfort with diffuse tenderness to
palpation- this is the reason the client presented to the office



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,  It is also important to view/determine the key finding list because, from a clinical
standpoint, the MSAP may differ from the client’s chief complaint.
 Bilious emesis: vomiting shows upper abdominal involvement in the disease
process, which refocuses the order of the differential diagnosis list. This is a
related key finding.
 High cholesterol: Hypercholesterolemia is both a positive and negative risk factor
for items on the differential diagnosis list and important to consider when
reasoning through the case. This is a related key finding.
 Prior abdominal surgeries 1+ years ago: Abdominal surgeries are a pivotal risk
factor for diseases on the differential list. The timing of these surgeries dictates
the order of similar diagnoses on the differential list. This is a related key
finding.
 Heavy alcohol use: Alcohol may predispose the patient to certain diagnoses on
the differential list. As a risk factor, this is a related key finding.
 Tachycardia: Alterations in vital signs like tachycardia indicate hydration status,
and in conjuction with other vital signs, severity of illness. Tachycardia is a
related key finding.
 Lack of fever: Lack of fever pivots reasoning away from infectious and
inflammatory conditions and shows severity of illness. This is a related key
finding.
 Absent bowel sounds, bowel movement and flatus: Absent bowel activity is a
pivotal key finding that grades the severity of the illness and provides order to the
differential diagnosis list. This is a related key finding.
 Abdominal distention and tympany: Distention and tympany together indicate air
in the abdominal cavity and so are related key findings that narrow the
differential.
 Additional PMH: Since the client does not have a prior chart, it is relevant to ask
about past history that may affect the reasoning as the visit progresses
 Additional SH: Since the client does not have a prior chart, it is relevant to ask
about social history that may affect reasoning as the visit progresses
 Medications/Allergies: Since this patient does not have a prior chart, building a
good medication/allergies history during the visit is necessary for diagnositic and
therapeutic reasoning
 ROS: No other constitutional, cardiorespiratory, gastrointestinal, or urinary
symptoms: checking on potententially-related and vital organ systems with ROS
screening questions is relevant in every patient visit.
 Communication: Elicit the patient’s perspective. Understanding the patient’s
perspective regarding their illness can guide diagnostic and therapeutic thought
and also build rapport and trust in the visit

Grading Tips Using the Rubric: in this area, be prepared to explain to students
why the following information is important and why points may be deducted.
Students often omit important subjective/objective data.

Focused health history (graded by i-Human): retrieve report from i-Human to provide
insight and guidance


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