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What are the top 3 differentials you would consider with the presumptive final diagnosis listed first?

What are the top 3 differentials you would consider with the presumptive final diagnosis listed first?

  • Crohn Disease (CD): This patient most likely has a relapse of her previously diagnosed  This disease is a chronic issue, with remission and relapse stages, associated with inflammation of the intestinal tract. CD can affect any portion of the gastrointestinal (GI) tract, but it is most commonly seen in the terminal ileum and colon (Burns & et al, 2017). Characteristically Crohn disease presents with abdominal pain and diarrhea, which this patient reports. Other clinical findings that indicate CD as a potential diagnosis is the presence of low grade fever, anorexia, and tobacco use.
  • Ulcerative Colitis (UC): Patients with UC may present with diarrhea, which may contain blood. They will usually report bowel movements that are frequent and small in volume. Many patients complain of colicky abdominal pain, urgency, tenesmus, and incontinence. The onset of symptoms is usually gradual, and symptoms are progressive over several weeks. Systemic symptoms including fever, fatigue, and weight loss may be present as well (Uptodate).
  • Appendicitis:  The symptoms that accompany appendicitis are subacute and vague. Patient may complain of intermittent crampy abdominal discomfort, malaise, and possibly a change in bowel habits. Anorexia and nausea are common. Fever is usually present. Some patients may experience diarrhea and urinary symptoms (Buttaro & et al, 2017).

What focused physical exam findings would be beneficial to know?  In further evaluating this patient it would be important to know temperature, nutritional status, presence of abdominal tenderness or mass, perianal and rectal examination findings. In crohn disease generalized abdominal tenderness or localized pain may be present.    Abdomen may have fullness or a discrete mass may be noted, most commonly in the right lower quadrant. The perianal exam my find skin tags, fistulae, ulcers, abscesses, and scarring (Medscape, 2019).

What diagnostic testing needs completed if any to confirm diagnosis?

To confirm diagnosis a CT of abdomen and colonoscopy would be needed. Labs that could be performed to begin narrowing down differential diagnoses include: CBC, CMP, LFT, ESR, CRP, Serum iron. For a patient with frequent or bloody diarrhea stool for culture, C-Diff, and ova and parasite would be beneficial (Buttaro & et al, 2017).

Using evidence based treatment guidelines note a treatment plan.

  1. Patient with suspected crohn disease should be referred to Gastroenterologist for evaluation.
  2. In addition to pharmacological treatment assessment and management of stress, depression, and anxiety should be included as part of the care of the Crohn disease patient.
  3. Smoking cessation counseling should be provided.
  4. Corticosteroids are used orally, rectally, or intravenously for acute inflammation of mild to moderate disease but are not intended for longterm use.
  5. Sulfasalazine is effective for treating symptoms of mild to moderate Crohn disease.
  6. Controlled ileal release budesonide at a dose of 9 mg once daily is effective and should be used for induction of symptomatic remission for patients with mild to moderate ileocecal Crohn disease (Lichtenstein, 2018).

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G. (2017). Pediatric Primary Care. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780323243384/

Buttaro, T. M., Trybulski, J., Polgar-Bailey, P., Sandberg-Cook, J. (2017). Primary Care: A Collaborative Practice. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780323355018/

Lichtenstein, G. R., Loftus, E. V., Isaacs, K. L., Regueiro, M. D., Gerson, L. B., & Sands, B. E. (2018). ACG Clinical Guideline: Management of Crohn’s Disease in Adults. The American Journal of Gastroenterology: Official Publication of the National Gastroenterological Association113(4), 481. Retrieved from https://search-ebscohost-com.southuniversity.libproxy.edmc.edu/login.aspx?direct=true&db=edo&AN=ejs45274503&site=eds-live

Medscape. (2019). Crohn disease clinical presentation. Retrieved fromhttps://emedicine.medscape.com/article/172940-clinical#b3

Uptodate. (2018). Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-prognosis-of-ulcerative-colitis-in-adults?search=ulcerative%20colitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

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