Lower Abdominal Pain with Burning Sensation during Urination

This essay discusses the case study of Mr. John, a 68-year-old man with lower abdominal pain and burning sensation during urination. It provides a critical analysis of his examination and history, following Nursing and Midwifery Council guidelines. The essay also discusses the causes, diagnosis, and treatment of lower abdominal pain, and the importance of history taking and physical examinations for healthcare professionals.

Lower abdominal pain with burning sensation during urination
Introduction
Advanced Clinical Practitioners is a healthcare professional whose main aim is to
meet needs of people or patient they provide care to. Advanced Clinical Practitioners is also
known as ACP whose main principal role is to bring transformation within care pathway of
patients in order to enhance overall quality of care provided to them in order to enhance
patient satisfaction level (Evans et al., 2020). In health care, ACPs are effective and efficient
leaders. Their interpersonal skills help in enhancing their efficiency and further help them in
enhancing or developing their professional skills, bring improvement within clinical practices
of advance level (Lamb et al., 2018). This essay will lay emphasis upon a case study of Mr.
John who is a 68 years of man lower abdominal pain with burning sensation whenever he
urinates. In this essay critical analysis of examination of Mr John will be done, his history
will be analysed. While doing this essay Nursing and Midwifery Council NMC (2018)
guidelines, and pseudonym were followed throughout the essay and any confidential
information during practice were not disclosed in this essay.
Background and Rational
Background of this essay will provide basic information about Lower Abdominal Pain
which is also known as LAP. There are various number of issues or factors that contributes in
increasing pain in lower abdominal. But most of its symptoms are similar to other conditions
because of which it becomes difficult to diagnoses factors because of which this pain occurs
(Walsh et al., 2006). When accidental care, primary care or emergency departments (AED)
comes into picture, this lower abdominal pain is found to be most common problem.
Symptoms of this lower abdominal pain might be acute, serious or chronic. Some of the most
common factors that can result in increasing or developing pain in lower abdominal are
stomach related or intestine related such as intestinal obstruction, Crohn’s disease,
appendicitis, colitis, Irritable Bowel Syndrome and many more (Shi et al., 2018; Bielfeldt et
al., 2009).
Each of the identified factors require different therapeutic strategies or approaches
and as a result it becomes important to identify main cause of pain in lower abdominal.

Diagnosis of cause is done by evaluating patient’s medical history, analysing and evaluating
their current health status or condition, conducting certain test in laboratory and conducing
various examination on patient. When this problem is identified or is flagged red then in such
cases it becomes extremely important to take quick and effective decisions by investigating
overall situation, and its seriousness (Cartwright and Knudson, 2008). Despite of this process
many times misdiagnosis of this condition might be done that can increase risk for patients
that can become a threat to their life (Osterwalder et al., 2020).
The main reason because of which this topic has been chosen for this essay is because
this problem occurs mostly in emergency department and with the help of this essay,
knowledge and understanding of nurses about pain in lower abdominal can be enhanced so
that they can become efficient in providing quick response and care to patients and timely
and proper treatment to patients can be provided. This will further help nurses in identifying
challenges that they can face in providing care for this issue to patients. This essay will
further help nurses to develop required skills, and learn to take quick decisions and do
diagnosis effectively.
History taking
Taking and evaluating history of patient (both family medical and personal medical
history) is one of the most important part of clinical consultation that help every healthcare
professional and it can help them in clarifying past history, symptoms and experience of
patient so that future plan for care can be developed (Fawcett and Rhynas, 2012). As per the
study of Bickley and Szillagyi (2017) comprehensive examination is the base of developing
knowledge of patient that can help in strengthening patient and healthcare professional bond.
History of patient can help practitioners to get clear understanding of case study of patient
and omit any kind of information which is not relevant.
However, there is no specific format that can be followed when treating or consulting
patient but still it is an important tool for practitioners in providing effective treatment to
patients. There is a process which is known as SBAT or Situation-Background-Assessment-
Recommendation process that can be used by professionals in assessing their patients (Tews
et al., 2012). But despite of this, always this process cannot be used because many times
when patients are in state of shock, disoriented or not in condition to speak anything
practitioners cannot use this process for identifying their condition (Samcam and Papa, 2015).

SBAR process in Mr John case: Mr John was referred to RRT via GP. RRT or rapid
response team within a hospital is set so that admissions due to community care can be
reduced and growing pressure on acute health services can be reduced. (NHS, 2020). As an
ACP student history of Mr John was taken, physical examinations module was conducted to
provide holistic care to patient. Under supervision of clinical facilitator a community matron
all the diagnosis were done as an ACP student. When Mr. John arrived he looked quite
relaxed, well- nourished, relaxed gait, posture and facial expression suggestive of a general
wellbeing and there was absence of acute distress and talking in full sentences (Innes et al.,
2018). Under direct supervision of facilitator consultation started with basic introduction and
by obtaining verbal consent his history was asked and some physical examinations were
conducted for development of strong therapeutic relationship with him for putting him to
ease.
During this time, he complained of pain in lower abdominal with burning sensation
while urinating from last 3 days. He further elaborated that this pain lasted for 10-15 minutes
and only after taking paracetamol symptoms would get relieved. He further added that this
pain was sharp during urination. On further questioning he denied that there was no urethral
discharge, no nausea, no weight loss, no swelling, no fever, no issues with bowels, no
swelling or pain in testacies or no other symptoms.
For effective pain analysis mnemonics SOCRATES, OLDCART and ICE were used which
enabled Mr. John So that he can explain his symptoms in objective and broad ways. Mr. John
said there was no radiation of pain and any inflammatory or relieving factors. The pain was
rated as 5/10 using Visual Analogue Scale (VAS) (Nicol et.al., 2012). He complained about
having pain in lower abdomen region and while urinating with burning sensation. This
disturbed him while sleeping but intruption of this pain on his daily activities was not much.
The investigation of his ideas, concerns, expectations (ICE) was done to understand why Mr.
John is seeking for help. At the time of history taking, he related the pain with the infection.
He explained that he did not have any previous history of such symptoms and there is no any
family history as well. He also took some antibiotic medicines expecting to get cured.
Kallergis (2000) explains that therapeutic works better when there is good communication
and exchange of information, thoughts and feelings. Mr. John shares his concerns and
phobias to enable a correct treatment.
Red Flags

New onset symptoms are mostly picked out by 'red flag' findings. Patients who are more than
65 years, the red flags are most likely to linked with the higher chances of cancer (Jones and
et.al., 2007). Research suggests that the clinical ignorance of red flags can lead to cancer
misdiagnosis (Redaniel and et.al., 2015). When Mr. John was questioned about the symptoms
like blood in stools, no changes in urine output, symptoms of malaise, rectal bleeding, altered
bowel habit, no obvious haematuria, he denied all and was identified with no 'red flags'. If
present could indicate cancer or hematemesis, it is observed that there is no any difficulty in
swallowing, unintentional weight gain and weight loss, no back pain and there were no
symptoms like fever or chills (Bickley and Szilagyi, 2017).
Previous medical history gave an idea of patient's overall health and also provides an
information about the present complaints (Douglas and et.al., 2009). There is a mnemonic
called JAMTHREADS that suggests the health-care professionals to ask specifoc questions to
observe the patient's present conditions and previous history (Cupples, 2011). By using the
JAMTHREADS mnemonic, it was revealed that he had a history of benign prostatic
hypertrophy two years ago. He was also diagnosed with hypertension in 2008, glaucoma in
2011, and slowly his vision was getting impacted as a result he started wearing specs. When
asked about the current medications, he was not taking internet acquired medicines,
homeopathic medicines, also Mr. John had no allergies. (See appendix 1 for current
medications).
In his social history, He was retired as a plumber 5 years ago, and lived with his wife
in a 3-bedroom house from past 50 year. He is independent with all living activites and
enjoys gardening. Mr. John enjoys brisk walking and jogs daily. He eats a normal and
balanced diet and does not follow any special diets. There is no habit of drinking alcohol and
also denied the present and past history of smoking. He does not face any mood swing and
depression, and had sound sleep until this issue.
For his family history, Mr. John revealed that both his parents died naturally within
the span of a year. He has 2 younger sisters who are fit and well. He is in contact with his
both children and has 3 grandchildren and they communicate and visit him regularly. No
significant family history is found, all are leading a good and healthy life.
Physical examinations and findings:
The patient's history and physical examination is an important aspect of any patient's
clinical check up (Innes and et.al.,2018). It is needed for the diagnosis and for finding other
differential diagnosis. For assessment of patient as critically ill or injured, an approach called

ABCDE is taken into the consideration (Olgers and et.al., 2017). It is an Aseptic technique
which is maintained throughout during the check-up, other than this verbal consent is also
taken from the patient to continue the examination. The examination was done in Mr. John's
bedroom, it was properly illuminated and was quiet. From his appearance, he was looking
well-groomed and there was no any sign of distress. By using a systematic approach for
collecting information, it was clear that he was able to talk fluently and was stable for the
physical examination. The major signs were checked for systemic illness or sepsis, they were
found to be within the normal range and shows that he was in haemodynamic stable
condition. It has supported the normal parameters of NEWS2 score =0 (Bickley and Szilagyi,
2017). (See appendix 2 for vital signs).
It is essential to check the surgical scars, changes in skin as it indicates signs of herpes
zoster, liver disease etc. (Innes and et.al.,2018). There were no sign of distress, no
xanthelasma, no central cyanosis and the face was perfused, no paleness and no sweating.
The eyes were normal, there was no indication of pallor on the sclera and conjunctiva as well
as showed no signs of anaemia. There were no sign of lever dysfunction and the cornel arcus
was also absent, showing no indication of increased cholesterol (Innes and et.al., 2018).
Supraclavicular nodes palpated for size, tenderness, shape all appeared normal. Enlarged
supraclavicular nodes mean metastatic disease, hard nodes means malignancy and tender
nodes indicates inflammation (Walsh and et.al., 2006). The mouth was also examined and no
symptoms like ulcer thrush or any sign of dehydration were found (Innes and et.al., 2018).
Hands were also examined, and it did not indicate stigmata of respiratory, the
circulation was good capillary refill were in less than 2 seconds, if it prolonged it shows sign
of dehydration. There was no stain of nicotine on nail bed, no clubbing, no leukonychia and
koilonychia. Hand skin was also in good condition, showed no evidence of oedema and
sweating. There is no any indication related to too much beta intakes and exhibits fine tremor
(Douglas and et.al., 2013; Shawcross and Wendon, 2012). Tactual examination for radio-
radio delay of the radial pulse was done, it exhibited to be normal rate, strong and steady
beating (Pickering, 2013). Mr. John's respiratory system indicated no chest pain, headaches,
joint pain and vertiginous also the general health was in normal condition.
He was questioned on having any pain or needed analgesia before examination of his
abdomen, he said the pain was not much and declined analgesia at that instant. The
abdominal examination was carried out methodically for any peculiarity through IPPA
(inspection, palpation, percussion, auscultation). These steps are followed to avert altered

bowel sound (Dains and et.al., 2016). Inspection was done from every angle. By standing on
the footboard side of the bed, it can be seen that the body shape was normal and no dilated
veins, scars, leisen, and no stretch marks suggesting ascites were visible (Ryder, 2011). It was
observed that Mr. John had normal aortic pulsation and abdominal peristalsis. There were no
sign of swelling and had no sign of caput medusa suggesting portal hypertension. Also, there
were no signs of intra-abdominal haemorrhage explained by Cullen's sign and Grey Turner's
sign (Aggarwal, 2011).
The second stage that is to be followed while abdominal examination is auscultation
(Estes, 2005). To prevent distortion in bowel sound by palpating the abdomen, auscultation is
followed for the inspection (Bickley and Szilagyi, 2017). The abdomen is divided into 4
quadrants, and the bowel sound is demonstrated in all the quadrants for auscultation. No
abnormal murmur sound was heard in aorta, iliac and renal arteries. No rub sound was found
over spleen and liver, splenic infarction and hepatoma can be found to be abnormal (Innes
and et.al.,2018). Also renal punch showed no tenderness.
While thumping on abdomen a rumbling and hollow sound was created, that means
abdominal gas was present, and it caused dullness (Cox, 2010). The palpation helps to find
the exact location and the size of the organ in the abdomen also helps to estimate the fluids
and points out the masses suggesting any tumour in abdomen (Bickley and Szilagyi, 2017). It
is performed in 9 quadrants of the abdomen. It was found that he had no visceromegaly,
swelling in internal organs and found normal resonance and fluids.
As per the findings of Epstein, (2008), abdominal palpation is performed for
assessing organs of the abdominal cavity to identify the tumour, fluids and muscles
contractions. Light palpation was carried in all the sections of the abdomen, no lumps were
found, tenderness was felt in suprapubic region. Deep palpation was performed and found to
be normal. An examination called negative rovsing and psoas indicated no inflammation in
the appendix (Rastogi and et.al., 2018). And the physical inspection explains that there was
no genital mass suggesting testicular cancer, also found no pulmonary and neurological
abnormalities.
The rectal process was elaborated to the patient under the supervision of the guardian,
and gained the verbal consent. The inspection of gluteal fold, posterior perineum and anus
was done and found no hemorrhoids and abscesses also found normal pathological
conditions. There were no evidence of GI bleeding and constipation and also exhibit empty
rectum (Knieling and Waldner, 2016).

As per the view point of Marieb and Hoehn, (2010), urinalysis should be done for
every patient with abdominal pain to exclude UTI (urine tract infection) and renal calculi. Mr.
John's urine sample was taken, from urinalysis it was observed that there was smell of
ammonia, the nitrite positive sediments were found, it was cloudy and had traces of protein
and leucocytes. The visual examination detects cloudy urine, and it suggests that the chances
of infection might be there. Cloudiness can be result of protein and dehydration or more
chronic conditions, UTI cannot be stated as confirmed from the cloudiness factor only (Bono
and Reygaret, 2020). Analysis of urine showed that there are sediments that are positive for
nitrite, there was presence of bacteria that reduces the nitrate that means bacterial infection
(Simerville and et.al.,2005). The leucocytes were also present that indicates the immune
system's response to fight with the unwanted bacteria (Den Heijer et.al., 2012). The pH value
of Mr. John's urine was 8.5. This shows the presence of urea-splitting bacteria like klebsiella
(Yang et.al., 2014). The urine sample shows no traces of blood.
Differential Diagnosis
In clinical reasoning process, the differential diagnosis is a very important part. It
provides the ease for the testing process, and also it validates the final diagnosis (Bosner
et.al., 2015). From the history takings and current physical examinations of Mr. John, a list of
differential diagnosis was made, these were UTI, renal colic, hernia, constipation,
pyelonephritis, cholecystitis, appendix, urinary retention, prostatitis (Bickley and Szilagyi,
2017). After that this is proceeded to the management.
With the help of differential diagnosis of MR. John, it was identified that there were
higher chances of UTI, as he was suffering with the pain in lower abdomen, the urine sample
showed that it was positive to nitrate and was visibly cloudy, also had particles of protein and
leucocytes. The pH level of urine was 8.5. According to NICE (national institute of health
and care excellence, 2015), this can be a sign of organisms building that can go further to
kidney, bladder and urethra. Urinary retention proves that there was no pain in lower area
also the patient was not feeling much pain to pass the urine. Rectal analysis exhibits no
inflammation. There was no hernia as no palpable mass was found at inguinal, umbilical,
femoral and abdominal regions. There was absence of tenderness while palpation of
costovertebral angle, this eliminates the chances of pyelonephritis. Also, there were no
symptoms of constipation, and found regular bowel movement (Lewis and et.al., 2014). The
absence of tenderness in upper part of abdomen, no sever pain and no vomiting and pyrexia

refutes the cholecystitis. The evidence of Rovsing and Psoa's were found to be negative
refutes the chances of acute appendicitis (Bickley and Szilagyi, 2017).
Management
MR. John was suffering with UTI. The clinical findings and plan of care were
discussed with the patient, to encourage the concordance of treatment and patient's
participation in making health-care decision (Hobden, 2006). The patient was not facing any
problems like, nausea and vomiting, hypotension, tachypnoea and tachycardia. His
haemodynamic condition was stable and seem to be good for home treatment. Taking
nitrofurantoin for 7 days is a first line treatment for UTI (NICE, 2018). Before prescribing,
renal impairment was inspected, and found no contraindication and interaction with his
present treatments (Joint formulary committee, 2020). Health care helper prescribed the
nitrofurantoin two times a day for 7 days to treat UTI. Paracetamol was also advised for the
patient to get relief from the abdominal pain. For determining the cause of infection, the urine
sample was sent to the laboratory.
In case of treatment failure, for management plan of patients and safe clinical
practice, safety netting is essential (Jones and et.al., 2019). If there was no improved or if
symptoms worsened in 48 hours of antibiotic treatment then in such case Mr. John was
advised to go to A&E or call on 111. He was also advised to visit to GP for the assessment if
there was no improvement within his symptoms even after 7 days of antibiotic treatment.
Also, he would be advised to take balanced diet, maintain personal hygiene and avoid
dehydration to avoid further infections.
It is concluded that, the author took a case study of a 68 year old man, suffering from
lower abdominal pain and at the time of urination he felt burning sensation. The diagnosis
reveals UTI issues. Proper treatment was prescribed for treating the UTI. As a health-care
practitioner, it is essential to complete history taking and physical examination to give a
proper treatment considering NICE guidelines and evidence based practice.

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APPENDIX 1 – HISTORY TAKING
Presenting complaint:
 Pain in lower abdominal part with sensation of burning while urination
Past medical history:
 Benign prostatic hypertrophy 3 years ago
 Hypertension in (2010)
 Glaucoma in 2011
 Reduced vision and wear glasses.
Current medication:
 Tamsulosin hydrochloride 400mcg,
 Carmellose 0.5% eye drops
 Amlodipine 10mg once a day
 Paracetamol 1g PRN
Other medication:
 No herbal medication was used
 No use of recreational drug
OTC (Over the counter):
 Occasional OTC Paracetamol for headache and pain.
Allergies:
 He has no known allergy from any drug.

 He has no known allergy from food or environment.
Sexual History:
 There is no pain, itchiness or any experience of soreness in groin, testicles and penis.
He has no any other sexual partner than his wife. There is no history of STDs.
Social history:
 In Mr. John's social history, he got retired 5 years as plumber.
 He lives in a 3 bedroom house with his wife from last 50 years.
 He enjoys gardening and does all his activities independently.
 He goes to jogging daily and likes brisk walking.
Alcohol:
 He does not drink alcohol
Smoking:
 He denied any current or past history of smoking
Diet:
 He eats normal diet and follows any special diet
 He takes balanced diet and fluids.
Travel:
 It's been more than 2 years, he hasn’t travelled overseas.
 COVID 19 Negative
Family history:
 Both his mother and father passed away in the same year naturally.
 He is elder brother of two sisters and they are healthy.
 Mr. John's 2 children and 3 grandchildren are in contact with him, and they visit him
regularly. There is no any major family history, all are healthy.
APPENDIX 2- PHYSICAL EXAMINATION FINDINGS

Vital signs:
 Temperature 36.2 degrees Celsius
 Pulse rate 73bpm regular rate and rhythm
 Respiratory rate 18bpm normal pattern
 Blood Pressure138/72 mmHg
 Oxygen saturation 98% on room air