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IRRITABLE BOWEL SYNDROME (IBS) WITH DIARRHEA

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CASE STUDY

 

HPI:

S.S a 60-year-old, African American female reports on going diarrhea with LLQ abdominal pains, for the past 4 days and described her pain as “crampy”. Pt goes avg of 2 times a day. She has been taking probiotics for 8 months, but the diarrhea never stops. Pt states she is sometimes has “gas” for which she takes Gas-X on a weekly basis, and often bloated. She denies blood in stool. Milk, and Ice cream aggravates her symptoms. Pt states that she cut out caffeine and has had some relief of symptoms. OTC Imodium has been helpful. Medical History: hernia repair (2016); hysterectomy (2000).

EXAMINATION

VITAL SIGNS:

Weight: 114 lbs; Height: 4′ 10.66″; BMI: 23.29; BP: 141/72(Right Arm)(Sitting); Pulse: 67;

Temperature: 99.5 F (Oral)

General Appearance: She is well groomed. She is alert. No weight loss.

Cardiovascular: PMI is nondisplaced and normal in character, no heave or abnormal pulsation. Normal sinus rhythm with normal S1 and S2 without audible click, murmur or rub.

Gastrointestinal: The abdomen is soft, non-tender without rebound or guarding. Normoactive bowel sounds are heard without rush. No palpable masses or hepatosplenomegaly is appreciated. No visible scars, hernias or sinuses are seen.

Musculoskeletal: SPINE- kyphosis.

Psychiatric: Speech is rapid. Flow and rhythm of speech appears to be normal. Patient is oriented to time, place and person, and situation.

 

 

DIAGNOSIS:

IRRITABLE BOWEL SYNDROME (IBS) WITH DIARRHEA

ASSIGNMENT TO BE COMPLETED:

PART A

Describe the patient’s diagnosis (IRRITABLE BOWEL SYNDROME (IBS) WITH DIARRHEA) AND WHY. Think about clinical guidelines that might support the diagnosis.

 

PART B

Use the template below to create management plan for two primary diagnoses related to this case study. (The diagnosis is (IRRITABLE BOWEL SYNDROME (IBS) WITH DIARRHEA)

 

MANAGEMENT PLAN TEMPLATE: (PLEASE USE BULLET POINTS)

Address the following:

 

1. PRIMARY DIAGNOSIS CPT and ICD-10 codes : (IRRITABLE BOWEL SYNDROME (IBS) WITH DIARRHEA) Explain reason for this diagnosis. Also include any procedural codes (CITE REFERENCE)

2. PROVIDE THREE DIFFERENTIAL DIAGNOSIS AND WHY. SUPPORT WITH EVIDENCE: Here are some differential diagnoses that can be used:(Diverticulitis, Gastroenteritis, Inflammatory Bowel Disease, Lactose Intolerance, Pancreatitis). List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis

 

3. LABORATORY AND DIAGNOSTIC TESTS: May be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.

 

4. CONSULTS: referrals to specialists, therapists (physical, occupational), counselors, or other professionals.

 

5. THERAPEUTIC MODALITIES: Pharmacological and Non-pharmacological management.

Pharmacological:

Non-pharmacological:

 

6. Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.

 

7. PATIENT EDUCATION: Explanations and advice given to patient and family members.

 

8. DISPOSITION/FOLLOW UP INSTRUCTIONS: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.

 

9. REFLECTION NOTE: What was your “aha” moment? What would you do differently in a similar patient evaluation?

10. REFERENCES: (minimum of 3, timely WITHIN THE LAST 5 years that prove this plan follows current standard of care).

The assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed within the past 5 years. (Please use 2 from the learning resources below). ThankS.

 

LEARNING RESOURCES

 

Buttaro, T. M., Polgar-Bailey, P., Sandberg-Cook, J., & Trybulski, J. (2021). Primary care: Interprofessional collaborative practice (6th ed.). Elsevier.

• Ch. 109, Abdominal Pain and Infections

• Ch. 111, Cholelithiasis and Cholecystitis

• Ch. 113, Constipation

• Ch. 114, Diarrhea, Noninfectious

• Ch. 115, Diverticular Disease

• Ch. 120, Inflammatory Bowel Disease

• Ch. 121, Irritable Bowel Syndrome

• Ch. 123, Nausea and Vomiting

• Ch. 124, Pancreatitis

 

 

Leik, M. T. C. (2018). Family nurse practitioner certification intensive review: Fast facts and practice questions (3rd ed.). Springer Publishing Company.

 

Centers for Disease Control and Prevention. (2020). https://www.cdc.gov/

 

Office of Disease Prevention and Health Promotion. (2020b). Healthy people 2020. https://www.healthypeople.gov/

 

Office of Disease Prevention and Health Promotion. (2020a). Development of the national health promotion and disease prevention objectives for 2030. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030

 

World Health Organization. (2020). https://www.who.int/

 

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