Case Study 2
A 40 year-old female presents to the office with the chief complaint of diarrhea. She has been having recurrent episodes of abdominal pain, diarrhea, and rectal bleeding. She has lost 9 pounds in the last month. She takes no medications, but is allergic to penicillin. She describes her life as stressful, but manageable. The physical exam reveals a pale middle- aged female in no acute distress. Her weight is 140 pounds (down from 154 at her last visit over a year ago), blood pressure of 94/60 sitting and 86/50 standing, heart rate of 96 and regular without postural changes, respiratory rate of 18, and O2 saturation 99%. Further physical examination reveals:
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Skin: w/d, no acute lesions or rashes
Eyes: sclera clear, conj pale
Ears: no acute changes
Nose: no erythema or sinus tenderness
Mouth: membranes pale, some slight painful ulcerations, right buccal mucosa, tongue beefy red, teeth good repair
Neck: supple, no thyroid enlargement or tenderness, no lymphadenopathy
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Cardio: S1 S2 regular, no S3 S4 or murmur
Lungs: CTA w/o rales, wheezes, or rhonchi
Abdomen: scaphoid, BS hyperactive, generalized tenderness, rectal +occult blood
- Think about a differential diagnosis. Consider the role the patient history and physical exam played in diagnosis.
- Reflect on potential treatment options based on your diagnosis.
By Day 3
Post an explanation of the differential diagnosis for the patient in the case study that you selected. Describe the role the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis.
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Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.
MODEL ANSWER
Week 6 Discussion Post
Analysis of gastrointestinal disorder ought to be handled with care due to complications associated with it. GI tract is one of the largest lymphoid organs in the human body and thus its manifestation is categorized into four types including; autoimmune, malignancy, inflammation and infection.
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Case Study Two
Differentials
A peculiar evaluation of the 40 years old female patient reveals that gastrointestinal bleeding is the most appropriate diagnosis. This is affirmed by the fact that the physical condition examination reveals that the patient have had a long time rectal bleeding and | PLACE YOUR ORDER NOW AT writtask.com | has lost a total of 14 pounds of the body weight having lost nine pounds in the previous month. This examination also reveals conditions such as pale conjunctiva, beefy red tongue and she has painful ulcerations, which might be as a result of pernicious | PLACE YOUR ORDER NOW AT writtask.com | is low and consequently it has dropped since it is approaching standstill while her heart rate is high. Further examinations reveal that the patient may be having pancreatic or primary gastric cancer as indicated…
One of the common findings in an ambulatory care setting is gastrointestinal bleeding. As such, there are various ways to manifest blood loss from GI tract, for instance, blood loss due Occult is interpreted in terms of anemia, which is caused by iron deficiency in the human body; this finding may also be achieved using chemical reagents (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2017). In fact, the findings are also extended to various…
Role of Patient History
To be able to identify critical signs of this condition, it is paramount to consider initial triage at the early age. Hypotension is only established in the body when the volume loss nears 40 percent. However, tachycardia is considered to be the earlier sign. Physical examination revealed that the patient pressure was standing at 85/50 and at 94/60 (sitting), therefore; it can be concluded that the female was losing a significant amount of blood at some point in the circulatory system. Buttaro (2017) supports these findings affirming that human blood pressure ….
Treatment Option
It is recommended that the patient should have immediate admittance to the hospital. Accordingly, the patient should be administered with a cross-match of 4 to six units of red blood cells to address her anemia condition; more so, the patient has dual large-bore intravenous streaks. In support of this treatment plan, Buttaro et al. (2017) suggests a…
Additionally, the patient should be placed under Foley catheter to help monitor her output in | PLACE YOUR ORDER NOW AT writtask.com | serum concentration and coagulation parameters accompanied by transfusion needs to be closely monitored. Per se, the best diagnostic approach chosen for this | PLACE YOUR ORDER NOW AT writtask.com | endoscopy using diagnostic test has proved to be successful and thus can help to attain hemostasis upon identifying a bleeding lesion (Buttaro et al., 2017). Surgical management for the patient is also supported by indicators such as 24 hours…
References
Penner, R. M., Fishman, M. B., & Majumdar, S. R. (2016). Evaluation of the adult with abdominal pain.
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