Three Differentials to Consider for The Medical Condition
It is evident in the case study that the results from the clinical evaluation will play a significant role in formulating the client’s final diagnosis. Nevertheless, only after considering all of the possible differential diagnoses can a definitive diagnosis be made.
After almost two weeks of dealing with sporadic digestive problems, the patient was finally diagnosed with Crohn’s disease based on the available evidence. Given the patient’s health history of Crohn’s disease (ICD-10-CM K50. 90), it seems likely that the two are related. Furthermore, because Crohn’s disease is an inflammatory bowel disorder, it can express anywhere in the digestive tract at whatever time (Cicero et al., 2019). The hallmarks of this illness are extreme exhaustion, chronic diarrhea, rapid weight loss, abdominal pain, as well as starvation. For the past 2 weeks, the patient has shown intermittent symptoms that are diagnostic of chronic inflammatory bowel disease.
Cholecystitis of ICD-10 code K81 also includes the persistent abdominal pain that the 18-year-old patient in the case study has been experiencing. Gallstones cause gallbladder inflammation by blocking the duct that carries bile from the gallbladder to the client’s small intestine (Vujic et al., 2019). It can cause severe discomfort, as well as lightheadedness, nausea, and vomiting.
Peptic Ulcer Disease
The second disease from the case study information that could be deduced from the presented signs and symptoms is peptic ulcer disease (ICD-10 code K27. 9). It is a health condition that manifests as open sores and lesions within the inner surfaces of the client’s abdomen. In some conditions, painful sores and lesions are encountered within the portions of the client’s duodenum, coupled with discomfort in the upper abdomen (Rao et al., 2022). It could radiate to the client’s abdominal area, vomiting, and fatigue.
Focused Physical Exam Findings
In any medical setting, a doctor or nurse must have a specific purpose in mind for the physical examination they order. The results of the physical exam will be utilized to help guide the diagnostic procedure and arrive at a definitive diagnosis in this case study. When deliberating among potential diagnoses, I would give weight to those based on findings from the physical examination.
The case study reveals that the patient is an addicted smoker who has been experiencing severe signs and symptoms, such as intermittent abdominal pain, for the past two weeks. Cigarette smoking has been linked to several cardiovascular and respiratory issues, including chronic cough, irregular heartbeat, high blood pressure signs and symptoms, as well as tachypnea.
Examination of the client’s chest, fingers, fluid retention, as well as the nasal cavity is recommended for detecting positive signs related to smoking. Since abdominal pain is the most prominent symptom, the doctor will likely ask the patient to lie face up so he or she can examine the belly (Vujic et al., 2019).
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A healthy external abdominal examination would then reveal a flat, soft abdomen without any palpable dilatation, scarring, or lesions. The abnormality includes a bloated lower abdomen, achy skin, and a generalized increase in abdominal size. The evaluation’s findings will be used to help the client’s healthcare providers zero in on a more specific diagnosis for the pain in their stomach.
The results of the diagnostic tests on the client will play a role in the final diagnosis implementation. According to the disclosed signs and symptoms, the healthcare professional is responsible for ordering the appropriate clinical assessments and diagnosis to arrive at a final diagnosis.
To reduce the list of possible diseases as well as reach a definitive diagnosis, numerous laboratory diagnostic procedures will need to be utilized in tandem. The first tool to be used is the stethoscope, which is typically applied to listen to and analyze cardiac rhythms as well as murmurs.
A stethoscope could be used to confirm the client’s pulse and the stomach will be listened to for possible bowel noises to pinpoint the damaged section of the digestive system. To identify individual abdomen and digestive tract parts, a digital colonoscopy examination, similar to a computerized colonoscopy, is essential. Using a virtual colonoscopy, the cause of abdominal pain was determined to be acute inflammation and foreign particles.
Further analysis may focus on the stomach’s contents as well as the existence of parasites, diseases, as well as germs that can cause disease (Talley et al., 2019). Blood tests for anti-Cdtb and anti-vinculin may be used as biomarkers for irritable bowel syndrome (IBS). There are other diseases, such as an infection with Helicobacter pylori, that may be detected with a simple blood test.
Application Of Evidence-Based Treatment Guidelines
Evidence-based treatment as well as management guidelines are widely recognized as essential by nurse practitioners and other healthcare professionals. As a result, the healthcare professional caring for the case study client has to consult the evidence-based treatment guidelines when deciding what measures to take. Clients who present with abdominal pain and are being treated for Crohn’s disease ought to have that disease treated. To lessen the inflammation caused by inflammatory bowel disease, immunosuppressants such as mercaptopurine (Purixan) and Azathioprine are commonly used.
They’ll be necessary for curing whatever illness is plaguing the patients (Pang et al., 2022). To successfully treat the client’s stomach problems, a clear lifestyle scheme, such as the client’s commitment to quitting smoking, will be required. Anyone who smokes and wants help managing their health ought to seek counseling and learn what they can. Planned changes to one’s lifestyle include engaging in routine physical activity and consuming fewer possibly hazardous foods such as caffeine, saturated fats, and tea.
Cicero, G., Ascenti, G., Bottari, A., Catanzariti, F., Blandino, A., & Mazziotti, S. (2019). Menterography: what is next after Crohn’s disease? Japanese Journal of Radiology, 37(7), 511–517. https://doi.org/10.1007/s11604-019-00838-y
Pang, C., Chen, Z. D., Wei, B., Xu, W. T., & Xi, H. Q. (2022). Military training-related abdominal injuries and diseases: common types, prevention, and treatment. Chinese Journal of Traumatology. https://doi.org/10.1016/j.cjtee.2022.03.002
Rao, G. V., Pal, P., Sekaran, A., Rebala, P., Tandan, M., & Reddy, D. N. (2022). Proposal of novel staging system CNM (Crohn’s primary site, nodes, mesentery) to predict postoperative recurrence of Crohn’s disease. Intestinal Research. https://doi.org/10.5217/ir.2022.00045
Talley, N. J., Holtmann, G., Walker, M. M., Burns, G., Potter, M., Shah, A., Jones, M., Koloski, N. A., & Keely, S. (2019). Circulating anti-cytolethal distending toxin b and anti-vinculin antibodies as biomarkers in community and healthcare populations with functional dyspepsia and irritable bowel syndrome. Clinical and Translational Gastroenterology, 10(7), e00064. https://doi.org/10.14309/ctg.0000000000000064
Vujic, J., Marsoner, K., Lipp-Pump, A. H., Klaritsch, P., Mischinger, H. J., & Kornprat, P. (2019). Non-obstetric surgery during pregnancy – an eleven-year retrospective analysis. BMC Pregnancy and Childbirth, 19(1). https://doi.org/10.1186/s12884-019-2554-6
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