The Assignment
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
Below is the SOAP note that you will analyze for your assignment this week. Review the information given. You will not be writing a SOAP note this week. Instead, write in a narrative format and address the following questions:
· Consider what history would be necessary to collect from the patient in the case study.
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Subjective:
· CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
· HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started
3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
· PMH: HTN, Diabetes, hx of GI bleed 4 years ago
· Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10
units qhs
· Allergies: NKDA
· FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN,
Hyperlipidemia, GERD
· Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
· VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
· Heart: RRR, no murmurs
· Lungs: CTA, chest wall symmetrical
· Skin: Intact without lesions, no urticaria
· Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
· Diagnostics: None
Assessment:
• Left lower quadrant pain• Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
The Assignment
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
adesola turner
on Sat, Jan 04 2020, 5:36 PM
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Submission ID: 7b178496-a714-4dfa-9e64-a9f27022edc3
wk6HealthAssessment x
Word Count: 1,203
Attachment ID: 2470875527
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Running head:
1
HEALTH ASSESSMENT 1
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HEALTH ASSESSMENT 1
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Health Assessment Information
HEALTH ASSESSMENT 1
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HEALTH ASSESSMENT 1
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Health Assessment Information
Health Assessment
Name
Institutional Affiliation
Health Assessment
2
In treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses (Ball, et al., 2015).
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In treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses (Ball, et al., 2015)
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In treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses (Ball, et al., 2015)
3
In the scenario given, the subjective portion could be more detailed by asking the patient more targeted questions about the pain they are experiencing.
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In the scenario given, the subjective portion could be more detailed by asking the patient more targeted questions about the pain they are experiencing
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However, in the case presented, the subjective portion could be more detailed with the use of more targeted questions about the pain they are experiencing
2
A good subjective history of present illness allows the practitioner to visualize what is going on with the patient before diagnostic testing is completed.
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A good subjective history of present illness allows the practitioner to visualize what is going on with the patient before diagnostic testing is completed
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A good subjective history of present illness allows the practitioner to visualize what is going on with the patient before diagnostic testing is completed (Dains, et al., 2016)
The patient reports that the pain started 3 days ago.
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The patient reports that the pain started 3 days ago
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The patient reports that the pain started 3 days ago
To inquire more about the onset of the pain, the patient should be asked, “How did the pain start?
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To inquire more about the onset of the pain, the patient should be asked, “How did the pain start
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To inquire more about the onset of the pain, the patient should be asked, “How did the pain start
Did it start gradually or all of a sudden” as well as what the patient was doing when the pain occurred.
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Did it start gradually or all of a sudden” as well as what the patient was doing when the pain occurred
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Did it start gradually or all of a sudden” as well as what the patient was doing when the pain occurred (Dains, et al., 2016)
The quality of pain needs to be investigated as well.
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The quality of pain needs to be investigated as well
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The quality of pain needs to be investigated as well
For example, colicky pain is often associated with forceful peristaltic contractions where as a poorly localized ache is associated with visceral peritonitis.
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For example, colicky pain is often associated with forceful peristaltic contractions where as a poorly localized ache is associated with visceral peritonitis
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For example, colicky pain is often associated with forceful peristaltic contractions whereas a poorly localized ache is associated with visceral peritonitis (Dains, et al., 2016)
In cases of abdominal pain, it is important to ask the patient about their bowel movements.
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In cases of abdominal pain, it is important to ask the patient about their bowel movements
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In cases of abdominal pain, it is important to ask the patient about their bowel movements (Dains, et al., 2016)
The characteristic, frequency, consistency, color and smell of the bowel movement can all be indicators of what processes are going on in the bowel (Ball, et al., 2015).
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The characteristic, frequency, consistency, color and smell of the bowel movement can all be indicators of what processes are going on in the bowel (Ball, et al., 2015)
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The characteristic, frequency, consistency, color and smell of the bowel movement can all be indicators of what processes are going on in the bowel (Ball, et al., 2015)
For example, frequent, loose, strong smelling diarrhoea is associated with Helicobacter pylori, which would signal the practitioner to order stool testing to test for the bacterium.
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For example, frequent, loose, strong smelling diarrhoea is associated with Helicobacter pylori, which would signal the practitioner to order stool testing to test for the bacterium
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For example, frequent, loose, strong smelling diarrhea is associated with Helicobacter pylori (H.Pylori), which would signal the practitioner to order stool testing to test for the bacterium (Ball, et al., 2015)
Inquiring more about the patient’s history with GI bleed would also help with understanding what procedures and GI tract disorders that the patient has had (Dains, et al., 2016).
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Inquiring more about the patient’s history with GI bleed would also help with understanding what procedures and GI tract disorders that the patient has had (Dains, et al., 2016)
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Inquiring more about the patient’s history with GI bleed would also help with understanding what procedures and GI tract disorders that the patient has had (Dains, et al., 2016)
The objective assessment in the scenario is adequate, with positive findings in the abdominal assessment only.
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The objective assessment in the scenario is adequate, with positive findings in the abdominal assessment only
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The objective assessment in the scenario is adequate, with positive findings in the abdominal assessment only
However, including assessments such as if the abdomen is distended by percussing the abdomen and measuring abdominal girth could be helpful to confirm if the abdomen is enlarged (Ball, et al., 2015).
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However, including assessments such as if the abdomen is distended by percussing the abdomen and measuring abdominal girth could be helpful to confirm if the abdomen is enlarged (Ball, et al., 2015)
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However, including assessments such as if the abdomen is distended by percussing the abdomen and measuring abdominal girth could be helpful to confirm if the abdomen is enlarged (Ball, et al., 2015)
4
The assessment is supported by the subjective information given.
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The assessment is supported by the subjective information given
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The assessment is supported by the subjective information given
The patient’s heartrate, blood pressure and temperature are mildly elevated, due to the 5/10 pain the patient is experiencing during the assessment.
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The patient’s heartrate, blood pressure and temperature are mildly elevated, due to the 5/10 pain the patient is experiencing during the assessment
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The patient’s heartrate, blood pressure and temperature are mildly elevated, due to the 5/10 pain the patient is experiencing during the assessment
2
The hyperactive bowel sounds correlate with the patient stating that they are having diarrhoea.
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The hyperactive bowel sounds correlate with the patient stating that they are having diarrhoea
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The hyperactive bowel sounds correlate with the patient stating that they are having diarrhea (Dains, et al., 2016)
The tenderness in the left lower quadrant (LLQ) is different from the generalized pain that the patient described, but the left lower quadrant could be the focal point of pain with referred pain in the other quadrants that are non-tender (Dains, et al., 2016).
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The tenderness in the left lower quadrant (LLQ) is different from the generalized pain that the patient described, but the left lower quadrant could be the focal point of pain with referred pain in the other quadrants that are non-tender (Dains, et al., 2016)
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The tenderness in the left lower quadrant (LLQ) is different from the generalized pain that the patient described, but the left lower quadrant could be the focal point of pain with referred pain in the other quadrants that are non-tender (Dains, et al., 2016)
On collecting diagnostic data, I would start off by ordering a series of lab tests to rule out possible infection, electrolyte imbalances or parasitic infections that could be causing the pain.
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On collecting diagnostic data, I would start off by ordering a series of lab tests to rule out possible infection, electrolyte imbalances or parasitic infections that could be causing the pain
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On collecting diagnostic data, I would start off by ordering a series of lab tests to rule out possible infection, electrolyte imbalances or parasitic infections that could be causing the pain
These would include a complete blood count (CBC), complete metabolic panel (CMP), Magnesium, Phosphate, occult stool and clostridium difficle stool (C.Diff) (Leblond, et al., 2014).
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These would include a complete blood count (CBC), complete metabolic panel (CMP), Magnesium, Phosphate, occult stool and clostridium difficle stool (C.Diff) (Leblond, et al., 2014)
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These would include a complete blood count (CBC), complete metabolic panel (CMP), Magnesium, Phosphate, occult stool and clostridium difficle stool (C.Diff) (Leblond, et al., 2014)
A high white count result from the CBC would indicate there is an infective process going on somewhere in the body and would require more diagnostic testing into the source of the infection (Leblond, et al., 2014).
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A high white count result from the CBC would indicate there is an infective process going on somewhere in the body and would require more diagnostic testing into the source of the infection (Leblond, et al., 2014)
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A high white count result from the CBC would indicate there is an infective process going on somewhere in the body and would require more diagnostic testing into the source of the infection (Leblond, et al., 2014)
The CMP would show liver, kidney and electrolyte function, excessive diarrhea can cause electrolyte imbalances that can cause changes in peristalsis and lead to abdominal pain (Leblond, et al., 2014).
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The CMP would show liver, kidney and electrolyte function, excessive diarrhea can cause electrolyte imbalances that can cause changes in peristalsis and lead to abdominal pain (Leblond, et al., 2014)
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The CMP would show liver, kidney and electrolyte function, excessive diarrhea can cause electrolyte imbalances that can cause changes in peristalsis and lead to abdominal pain (Leblond, et al., 2014)
An occult stool would test if the patient is having bleeding in the intestine that is not grossly seen (Leblond, et al., 2014).
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An occult stool would test if the patient is having bleeding in the intestine that is not grossly seen (Leblond, et al., 2014)
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An occult stool would test if the patient is having bleeding in the intestine that is not grossly seen (Leblond, et al., 2014)
Testing for C.
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Testing for C
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Testing for C
Diff would rule out a Pylori infection.
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Diff would rule out a Pylori infection
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Diff would rule out a Pylori infection
For imaging, I would order a CT abdomen, with or without contrast (based on glomular filtration rate in CMP), in order to view any organ abnormalities.
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For imaging, I would order a CT abdomen, with or without contrast (based on glomular filtration rate in CMP), in order to view any organ abnormalities
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For imaging, I would order a CT abdomen, with or without contrast (based on glomular filtration rate in CMP), in order to view any organ abnormalities
A CT scan is the gold standard of visualizing visceral function in acute abdominal pain.
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A CT scan is the gold standard of visualizing visceral function in acute abdominal pain
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A CT scan is the gold standard of visualizing visceral function in acute abdominal pain (Leblond, et al., 2014)
The impression and findings found in the CT scan would determine if the patient requires any immediate surgical interventions (Leblond, et al., 2014).
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The impression and findings found in the CT scan would determine if the patient requires any immediate surgical interventions (Leblond, et al., 2014)
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The impression and findings found in the CT scan would determine if the patient requires any immediate surgical interventions (Leblond, et al., 2014)
An abdominal x-ray and LLQ ultrasound (US) would be helpful in visualizing this specific area if a CT is not available (Leblond, et al., 2014).
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An abdominal x-ray and LLQ ultrasound (US) would be helpful in visualizing this specific area if a CT is not available (Leblond, et al., 2014)
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An abdominal x-ray and LLQ ultrasound (US) would be helpful in visualizing this specific area if a CT is not available (Leblond, et al., 2014)
An Esophagogastroduodenoscopy (EGD) might be performed since the patient has a positive history for GI bleed, based on the results from the occult stool testing (Leblond, et al., 2014).
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An Esophagogastroduodenoscopy (EGD) might be performed since the patient has a positive history for GI bleed, based on the results from the occult stool testing (Leblond, et al., 2014)
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An Esophagogastroduodenoscopy (EGD) might be performed since the patient has a positive history for GI bleed, based on the results from the occult stool testing (Leblond, et al., 2014)
5
I would accept the current diagnosis of gastroenteritis, due to the fact that the patient describes subjective data correlates with the symptoms of gastroenteritis with diarrhea, nausea and generalized abdominal pain ().
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I would accept the current diagnosis of gastroenteritis, due to the fact that the patient describes subjective data correlates with the symptoms of gastroenteritis with diarrhea, nausea and generalized abdominal pain ()
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I would accept the current diagnosis of gastroenteritis, due to the fact that the patient describes subjective data correlates with the symptoms of gastroenteritis with diarrhea, nausea and generalized abdominal pain ()
2
The physical assessment could be indicative of gastroenteritis, with a slight elevation in body temperature due to inflammation (Ball, et al., 2015).
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The physical assessment could be indicative of gastroenteritis, with a slight elevation in body temperature due to inflammation (Ball, et al., 2015)
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The physical assessment could be indicative of gastroenteritis, with a slight elevation in body temperature due to inflammation (Ball, et al., 2015)
The tenderness in the LLQ is not specific to gastroenteritis but can be a major area of inflammation causing tenderness to the area (Dains, et al., 2016).
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The tenderness in the LLQ is not specific to gastroenteritis but can be a major area of inflammation causing tenderness to the area (Dains, et al., 2016)
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The tenderness in the LLQ is not specific to gastroenteritis but can be a major area of inflammation causing tenderness to the area (Dains, et al., 2016)
I would still order an LLQ US or CT to rule out any other processes in this area (Leblond, et al., 2014).
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I would still order an LLQ US or CT to rule out any other processes in this area (Leblond, et al., 2014)
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I would still order an LLQ US or CT to rule out any other processes in this area (Leblond, et al., 2014)
Ulcerative Colitis Ulcerative colitis (UC) would be a differential diagnosis due to the patient’s history of GI bleed in the past and current symptoms.
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Ulcerative Colitis Ulcerative colitis (UC) would be a differential diagnosis due to the patient’s history of GI bleed in the past and current symptoms
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Ulcerative Colitis The differential diagnosis would be Ulcerative colitis (UC) due to the patient’s history of GI bleed in the past and current symptoms
5
The diagnosis would account for the rise in body temperature, differentiating pain levels, and diarrhea.
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The diagnosis would account for the rise in body temperature, differentiating pain levels, and diarrhea
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The diagnosis would account for the rise in body temperature, differentiating pain levels, and diarrhea
2
Recent studies into more conclusive biomarkers for more accurate diagnosis of UC have shown that protein identification and quantification using mass spectrometry could potentially differentiate UC from other bowel inflammatory bowel diseases (Barnes & Burakoff, 2016).
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Recent studies into more conclusive biomarkers for more accurate diagnosis of UC have shown that protein identification and quantification using mass spectrometry could potentially differentiate UC from other bowel inflammatory bowel diseases (Barnes & Burakoff, 2016)
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Recent studies into more conclusive biomarkers for more accurate diagnosis of UC have shown that protein identification and quantification using mass spectrometry could potentially differentiate UC from other bowel inflammatory bowel diseases (Barnes & Burakoff, 2016)
Sigmoid Diverticulitis Sigmoid Diverticulitis is when small bulging pouches develop in the sigmoid colon, in which food can collect in these pouches, causing them to inflame (Almerie & Simpson, 2015).
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Sigmoid Diverticulitis Sigmoid Diverticulitis is when small bulging pouches develop in the sigmoid colon, in which food can collect in these pouches, causing them to inflame (Almerie & Simpson, 2015)
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Sigmoid Diverticulitis Sigmoid Diverticulitis is when small bulging pouches develop in the sigmoid colon, in which food can collect in these pouches, causing them to inflame (Almerie & Simpson, 2015)
This would correlate with the diarrhea, LLQ pain, and slightly elevated temperature the patient is experiencing.
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This would correlate with the diarrhea, LLQ pain, and slightly elevated temperature the patient is experiencing
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This would correlate with the LLQ pain, diarrhea,and slightly elevated temperature the patient is experiencing
Diverticulosis of the bowel needs to be diagnosed before a diagnosis of diverticulitis can be confirmed, this is best done with a CT abdomen (Almerie & Simpson, 2015).
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Diverticulosis of the bowel needs to be diagnosed before a diagnosis of diverticulitis can be confirmed, this is best done with a CT abdomen (Almerie & Simpson, 2015)
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Diverticulosis of the bowel needs to be diagnosed before a diagnosis of diverticulitis can be confirmed, which is done best with a CT abdomen (Almerie & Simpson, 2015)
Regional Ileitis Inflammation of the ileus can cause increase in body temperature, localized pain to the LLQ, loss of appetite, nausea, vomiting and diarrhea.
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Regional Ileitis Inflammation of the ileus can cause increase in body temperature, localized pain to the LLQ, loss of appetite, nausea, vomiting and diarrhea
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Regional Ileitis Inflammation of the ileus can cause increase in body temperature, localized pain to the LLQ, loss of appetite, nausea, vomiting and diarrhea
The patient has had all of these symptoms, except for vomiting.
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The patient has had all of these symptoms, except for vomiting
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The patient has had all of these symptoms, except for vomiting
The diagnosis of regional ileitis often is associated with Crohn’ Disease (CD), but ileitis can occur without the presence of CD, and should be investigated efficiently to decrease delays or misdiagnosis (Gajendran, Loganthan & Catinella, 2018).
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The diagnosis of regional ileitis often is associated with Crohn’ Disease (CD), but ileitis can occur without the presence of CD, and should be investigated efficiently to decrease delays or misdiagnosis (Gajendran, Loganthan & Catinella, 2018)
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The diagnosis of regional ileitis often is associated with Crohn’ Disease (CD), but ileitis can occur without the presence of CD, and should be investigated efficiently to decrease delays or misdiagnosis (Gajendran, Loganthan & Catinella, 2018)
References Almerie, M.
2
Q., & Simpson, J.
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Q., & Simpson, J
Source – Another student’s paper
Q., & Simpson, J
(2015).
2
Diagnosing and treating diverticular disease.
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Diagnosing and treating diverticular disease
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Diagnosing and treating diverticular disease
The Practitioner, 259(1785), 29.
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The Practitioner, 259(1785), 29
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The Practitioner, 259(1785), 29
Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=26591654&site=ehost-live&scope=site
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Source – Another student’s paper
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Ball, J.
2
W., Dains, J.
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W., Dains, J
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W., Dains, J
E., Flynn, J.
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E., Flynn, J
Source – Another student’s paper
E., Flynn, J
A., Solomon, B.
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A., Solomon, B
Source – Another student’s paper
A., Solomon, B
S., & Stewart, R.
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S., & Stewart, R
Source – Another student’s paper
S., & Stewart, R
W. (2015).
2
Seidel’s guide to physical examination (8th ed.).
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Seidel’s guide to physical examination (8th ed.)
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Seidel’s guide to physical examination (8th ed.)
St. Louis, MO: Elsevier Mosby.
Barnes, E.
2
L., & Burakoff, R.
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L., & Burakoff, R
Source – Another student’s paper
L., & Burakoff, R
(2016).
2
New Biomarkers for Diagnosing Inflammatory Bowel Disease and Assessing Treatment Outcomes.
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New Biomarkers for Diagnosing Inflammatory Bowel Disease and Assessing Treatment Outcomes
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New Biomarkers for Diagnosing Inflammatory Bowel Disease and Assessing Treatment Outcomes
Inflammatory Bowel Diseases, 22(12), 2956–2965.
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Inflammatory Bowel Diseases, 22(12), 2956–2965
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Inflammatory Bowel Diseases, 22(12), 2956–2965
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Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=27763951&site=ehost-live&scope=site
Source – Another student’s paper
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Dains, J.
2
E., Baumann, L.
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E., Baumann, L
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E., Baumann, L
C., & Scheibel, P.
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C., & Scheibel, P
Source – Another student’s paper
C., & Scheibel, P
(2016).
2
Advanced health assessment and clinical diagnosis in primary care (5th ed.).
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Advanced health assessment and clinical diagnosis in primary care (5th ed.)
Source – Another student’s paper
Advanced health assessment and clinical diagnosis in primary care (5th ed.)
St. Louis, MO: Elsevier Mosby.
2
Gajendran, M., Loganathan, P., Catinella, A.
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Gajendran, M., Loganathan, P., Catinella, A
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Gajendran, M., Loganathan, P., Catinella, A
P., & Hashash, J.
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P., & Hashash, J
Source – Another student’s paper
P., & Hashash, J
G. (2018).
2
A comprehensive review and update on Crohn’s disease.
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A comprehensive review and update on Crohn’s disease
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A comprehensive review and update on Crohn’s disease
Disease-A-Month:
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Disease-A-Month
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Disease-A-Month
DM, 64(2), 20–57.
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DM, 64(2), 20–57
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DM, 64(2), 20–57
https://doi-org.ezp.waldenulibrary.org/10.1016/j.disamonth.2017.07.001
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https://doi-org.ezp.waldenulibrary.org/10.1016/j.disamonth.2017.07.001
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https://doi-org.ezp.waldenulibrary.org/10.1016/j.disamonth.2017.07.001
LeBlond, R.
2
F., Brown, D.
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F., Brown, D
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F., Brown, D
D., & DeGowin, R.
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D., & DeGowin, R
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D., & DeGowin, R
L. (2014).
2
DeGowin’s diagnostic examination (10th ed.).
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DeGowin’s diagnostic examination (10th ed.)
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DeGowin’s diagnostic examination (10th ed.)
New York, NY:
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New York, NY
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New York, NY
McGraw Hill Medical.
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McGraw Hill Medical
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McGraw Hill Medical
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