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Introduction
I work as a Diabetes Specialist Nurse (DSN) in the Hospital, where my main job role is to provide assessment, review and treatment for the diabetic patients. I also have the responsibility to educate other health care professionals and educate diabetic patients about self-management of diabetes. Cable (2016) argues that the DSN`s plays a central role in the provision of diabetic care within primary and secondary care and is one of the most active participants within the multiple disciplinary team (MDT). Through the principles of physical assessment module my aim is to develop my knowledge and skills to an advanced nursing level to work more autonomously thereby provide better care for my patients. According to Department of Health (DOH, 2010) nurses working at an advanced level promote public health and well-being. DOH (2010) argues that an advance nurse understand the implications of the social, economic and political context of healthcare and their expertise, experience and professional and clinical judgement are demonstrated in the expert nature of their practice and the depth of knowledge. Nurses working at an advanced level use complex reasoning, critical thinking, reflection and analysis to inform their assessments, clinical judgements and decisions (DOH 2010). In this assignment I aim to look into clinical decision making in early diagnosis of bowel obstruction in one of the diabetic patients who presented with Diabetic Ketoacidosis (DKA) and abdominal pain. These will presented through a reflection of a case study of a patient I assessed at my area of practice.

I was called out to review a diabetic patient Mrs C, who was being treated for DKA at Acute Medical Unit (AMU). According to Kitabchi and Nematollahi (2017) DKA is an acute metabolic complication of diabetes characterised by a biochemical triad of hyperglycaemia, ketonaemia, and acidaemia and it is potentially fatal if not properly treated. Most common presenting symptoms of DKA are vomiting and abdominal pain ( Umpierrez and Freire, 2002).
On arrival to the ward Mrs C appeared to be in pain and discomfort. Following introduction informed consent was gained prior to collecting a detailed history and physical examination. According to the Nursing and Midwifery Council (NMC, 2015) all registered nurses are accountable for obtaining to get properly informed consent and document it before carrying out any actions.
Summerton (2008) argues that the medical history is a powerful diagnostic technology. Jarvis (2011) suggests that interview / history taking is the first and important part of data collection. Jarvis (2011) highlights how a complete history and physical assessment can be a big data to distinguish the relevant from the irrelevant that is important for the health problem or health promotion, and this can be a challenge for a new examiner. The clinical history and physical exam are critical to the diagnostic process and often provide more information than can be gained by broad testing strategies (Muhrer, 2014). UNC School of Medicine (2017) strongly agrees with, stating that the ability to obtain an accurate medical history and carefully perform a physical examination is fundamental to providing comprehensive care to adult patients.
On history taking, Mrs C a 68 yrs. old married woman came to the hospital with the complaints of abdominal pain, nausea, vomiting, elevated blood glucose levels and ketones. She had been suffering with nausea and abdominal pain for two days. Mrs C has colicky pain and more to the left side of abdomen not persistent all the time. She had not had bowels opened for 5 days, judged as due to poor dietary intake. She was a known type 1 diabetic since the age of 25yrs and on four time’s daily insulin. Her diabetes was poorly controlled and recent HbA1c is 96mmol/mol. Mrs C missed her insulin frequently. Apart from diabetes she also took medication for hypertension. She had appendectomy performed at the age of 20 yrs. and history of two caesarean sections. Mrs C was normally independent and self-caring. She lives with her husband and she was a mother for two children. She used to work as school teacher and now retired two years ago. Mrs C is on Lantus 40 units at am, Novorapid 15 units three times daily with meals and on Amlodepine 5mg once daily for hypertension. Mrs C takes Ibuprofen at times for generalised pain. Though the DKA was resolving Mrs C`s vomiting and pain abdomen weren’t settling. This leaded to a full examination of the abdomen. According to Macaluso and McNamara (2012) on pain abdomen assessment location of pain , character, onset, intensity, and where else feel it, what makes it worse or better, how it has changed over time, and whether they have ever had it before, these histories are very important to make final diagnosis.
According to Jarvis (2011) skills required for physical examination are inspection, palpation, percussion and auscultation and better performed in the above order one at a time. Bickley (2012) argues that physical examination relies on the above four cardinal techniques. Jarvis (2011) strongly recommends depart from the usual examination sequence and auscultation of abdomen should be done after inspection because percussion and palpation can increase peristalsis, which would give false interpretation of bowel sounds.

The examination of abdominal system was performed with inspection, auscultation, palpation and percussion to determine the urgency of the situation. Physical examination was started with inspection from foot end of bed, Mrs C appeared to be in pain and discomfort, but alert and oriented. Mrs C was treated for DKA on a fixed rate of intravenous insulin infusion. Vital signs were checked. Vital signs include the measurement of: temperature, respiratory rate, pulse, blood pressure and blood oxygen saturation and these numbers provide critical information about a patient’s state of health (University of California Sandiego, 2009). Mrs C`s blood pressure was 140/70mmof Hg, temperature-36.6c, heart rate- 96/mt, respiratory rate- 20/mt and oxygen saturation 97% on air. Rathmell and Fields (2012) states that acute pain is associated with a stress response consisting of increased blood pressure and heart rate. Vital signs that fall outside of expected ranges must be correlated with the overall clinical presentation (Kerkar, 2018). Dehydration not only leads to loss of water but also cause loss of electrolytes this increases the workload on the heart and it beats faster resulting in tachycardia (Kerkar, 2018).
Reuben (2016) argues that much can be learnt from non-touch inspection with a keen eye. Abdominal distension may be caused by central obesity, ascites, and enlargement of intra-abdominal organs, gas, constipation and malignancy. On inspection of abdomen, abdomen was distended and symmetric bilaterally. Mrs C had midline surgical scar, running from the Xiphisternum to the midpoint between the umbilicus and pubic symphysis that was the scar from previous caesarean section. Also another scar was noticed on right side of abdomen (appendectomy scar). No mass or protrusions were noted. Auscultation of the abdomen is performed for detection of altered bowel sounds, rubs, or vascular bruits is accomplished by placing the diaphragm of the stethoscope lightly in close contact with the abdominal wall (Jarvis, 2011). The stethoscope is used to listen over several areas of the abdomen for several minutes for the presence of bowel sounds (Ferguson, 1990). Normal peristalsis creates bowel sounds that may be altered or absent by disease (Jarvis, 2011). Jarvis (2011) strongly recommends beginning auscultation in the right lower quadrant at the ileocecal valve area because bowel sounds are normally always present there. Lampert (2016) suggests listening over all four quadrants of abdomen, not simply in one place. Lampert (2016) also recommends in fact, several areas per quadrant would be ideal, especially in patients who have gastrointestinal (GI) issues. On auscultation of Mrs C`s abdomen bowel sounds were reduced or hypoactive. Nursing Link (2018) strongly recommends listen for 5 minutes to each quadrant before deciding that bowel sounds are absent. Listened to the bowel sounds for five minutes in upper right and left quadrant and lower right and left quadrant. Bowel sounds were absent on lower quadrant and hypo active on upper quadrant. Finding no bowel sounds can mean an ileus, or an obstruction above that area of the intestine. Hypoactive bowel sounds could indicate a problem.
Reuben (2016) suggests that palpation should be approached cautiously and gently, especially in the patient complaining of abdominal pain. Abdominal tenderness is the objective expression of pain from palpation (Ferguson, 1990). Examination of the abdomen should begin with light palpation in all four quadrants, looking for and noting masses, guarding—voluntary or involuntary—and tenderness both with application of pressure and its release, that is, rebound tenderness that reflects peritoneal inflammation ( Jarvis, 2011). Reuben (2016) states that palpation while the patient flexes the abdominal muscles can help distinguish local from deep tenderness, and abdominal wall masses from those arising from intra-abdominal structures. Mrs C `s abdominal palpation revealed that she was very tender on below umbilicus more on left side. No mass was felt on palpation. At this point I felt that my knowledge in the physical examination helped me to undertake a proper examination of Mrs C.

Jarvis (2011) recommends that percussion will help to assess the relative density of abdominal contents, to locate organs and to screen for abnormal fluid or masses. Tuteur (1990) suggests that to make this interpretation it is important not only to listen for the sound produced but also to feel the intensity and frequency of vibrations produced by this manoeuvre. Despite rapid advances in imaging techniques, abdominal percussion remains an essential part of a physical examination (Fedorowski, 2000). Correct percussion technique is critical for this method to be effective. Percussion collects data by vibrations and sounds ( Fedorowski, 200) . For abdominal examination, percussion is used to assess the amount of fluid or gas, the location of mass, the size of liver and spleen (Jarvis, 2011). Normally, tympanic sound is found at hollow organs such as stomach and intestine; dullness sound is found at liver, spleen or masses (Jarvis 2011). Mrs C was rolled to right side and percussion performed from top to bottom. On percussion Mrs C`s abdomen was hyper resonant. Hopkins (2017) suggest that abdominal distension may be significant in patients with a large-bowel obstruction (LBO). Hopkins (2017) states that the bowel sounds may be normal early on but usually become quiet. Vomiting is usually present in small bowel obstruction (Macaluso and McNamara, 2012). According to Umpierrez and Freire (2002) the cause of abdominal pain was considered to be secondary to the precipitating cause of metabolic decompensating. Common medical conditions mimicking acute abdomen include basal pneumonia, diabetic keto acidosis are serious surgical conditions which are commonly missed and misdiagnosed (Durai, Hoque and Ng P, 2010). A focused history, physical examinations and adjunctive testing strategy will allow for those patients with concerning presentations to be identified, initially managed and appropriately referred for continued care ( Flasar, Cross and Goldberg, 2006 ) . Intestinal obstruction involves a partial or complete blockage of the bowel. Abdominal symptoms such as distension, pain, cramping, vomiting, and constipation are common.

Mrs C` was diagnosed with bowel obstruction from physical examination findings. Science direct (2013) strongly recommends that radiographic films should be conducted to evaluate the extent of the obstruction. The initial imaging study should be comprised of plain films of the abdomen and chest (science direct, 2013). A computed tomography (CT) scan should be done for patients with inconclusive plain films or a worsening abdominal examination (science direct, 2013). In order to confirm the diagnosis Mrs C was referred for abdominal X-ray and CT scan. Doctors reviewed the X-ray and CT scan reports and confirmed as intestinal obstruction and Mrs C was referred to surgeons for further management.

Conclusion
In conclusion, this case study highlights that thorough physical examination is a crucial component in the management of pain abdomen with diabetic ketoacidosis. Umpierrez and Freire (2002) found abdominal pain in 46% of patients with DKA in their study. According to Macaluso and McNamara (2012) although abdominal pain is a common presentation in DKA, it must be approached in a serious manner, as it is often a symptom of serious disease and misdiagnosis may occur. Some early symptoms of bowel obstruction will be easily misdiagnosed in DKA. Therefore, collecting health history and physical examination are very important. It supports a fast and accurate diagnosis in order to provide appropriate treatments to solve the patient’s problem and the symptoms at the same time. Breum et al (2015) states that early diagnosis and treatment of bowel obstruction is imperative to reduce the risk of intestinal strangulation, necrosis and perforation. A focused evaluation for potential aetiologies of diabetic ketoacidosis is warranted in all patients in order to not miss rare causes (Natalini et al., 2017). Umpierrez and Freire (2002) strongly suggest that further investigation of abdominal pain in DKA should be reserved for patients who suffer from persisting pain without severe metabolic acidosis or if the pain persists after the resolution of ketoacidosis. Abdominal pain in case of diabetes is usually interpreted as a presentation of DKA, but sometimes is may not be the only cause of pain in abdomen and can be misguiding to the physician’s too (Margekar et al., 2014).

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