A 78-year-old woman, Ms. Sailor reports to
A 78-year-old woman, Ms. Sailor reports to the clinic with her adult daughter, whom she lives with. She has been experiencing left-sided lower abdominal pain for the past 3 days. The daughter reports that her mother began complaining of bloating sensation and left-sided pain that was not relieved with antacids and acetaminophen. Additionally, for the last 2 days, the daughter states that her mom has not had much of an appetite and complains of sharp, crampy abdominal pain when she does eat. The daughter reports that her mother seems to be confused, which is not her typical orientation, as her mother still drives and is a volunteer in the community center, where she is the receptionist 3 days a week. Past medical history includes osteoarthritis, for which the patient takes OTC NSAIDs daily, and long-term constipation, which she treats with herbal products and OTC remedies. Her social history: smoked one pack of cigarettes a day for 30 years. Besides volunteering at the community center, she limits her physical activity to weekly housekeeping and walking from parking lots to stores. She has NKDA. Physical Exam: Vital Signs: Temperature 99°F, pulse 80 beats per minute, respirations 22 breaths per minute, blood pressure 135/80 mm Hg. Height – 66 inches, Weight – 189 lbs. Constitutional: Alert and oriented to person and place. Follows commands appropriately. HEENOT: Oral mucosa pink; slightly dry. Full dentures noted. CV: S1 S2. RRR without murmur. Capillary refill brisk. 2+ peripheral pulses Resp: Lungs CTA bilaterally. No adventitious sounds. GI: Abd. soft, slightly tender with deep palpation to LLQ. Normoactive bowel sounds. GU: No suprapubic or CVA tenderness FOR DISCUSSION: Using the 2021 American Gastroenterological Association (AGA) Clinical Practice Update (CPU) Expert Review Guidelines, complete the Assessment and Plan for Ms. Sailor to include the following: Assessment: Primary Diagnosis: Include ICD10 codes in parentheses next to the diagnosis. Include a brief pathophysiology along with pertinent positive and negative findings to support your diagnoses Secondary Diagnoses: Include ICD10 codes in parentheses next to the diagnosis. Include brief pathophysiology along with pertinent positive and negative findings to support your diagnoses. Differential Diagnoses: (list a minimum of 3 differential diagnoses. Include ICD10 codes in parentheses next to the diagnosis. Include a brief pathophysiology along with pertinent positive and negative findings to support your diagnoses. Plan: (for the primary diagnosis) Provide a rationale and evidence-based in-text citation for each intervention Diagnostics: List all diagnostic tests or screenings to be ordered or completed.
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