INTRODUCTIONThis is a case study concerning a patient presenting with low abdominal pain, frequent micturation and dysuria. I will discuss the consultation and show how I used the problem solving consultation style detailed by Alison Crumbie. This involves listening to the patients' initial complaint and developing hypothetical diagnosis. Focused questioning and clinical examination and investigations will then be used to eliminate some of the initial hypotheses. The patients' perspective of their problem will be addressed and the synthesis of gathered information will enable the practitioner to arrive at a differential diagnosis and to agree on a treatment plan with the patient so that they can manage their problem.
Abdomen: The lipases appeared unremarkable. The liver, spleen, gallbladder adrenals, kidneys, pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seemed consistent with acute appendicitis. All the structures of the abdomen appeared unremarkable. No free air was seen.
T.B. is a 65-year-old retiree who is admitted to your unit from the emergency department (ED). On arrival you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid-back as a deep, sharp boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but “none as bad as this.” He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fish and chips
Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.
Imran Haque is connected with many different hospitals in the area, He is one of 15 doctors at Randolph Hospital and one of six doctors at Kindred Hospital-Greensboro who specialize in Internal
Rauf Abayev has been volunteering at this hospital for over a year now. In addition to volunteering, he has been shadowing the PAs in the general surgery clinic under my supervision. Furthermore, I have come to know him quite well when he shadowed me during the whole summer. It is a pleasure to be able to provide this letter of recommendation for him for admission to the PA program.
* Refer to primary care doctor to address ongoing pain in stomach client reported it uncontrolled for several month with over the counter medications and to rule out any other medical problems or symptoms.
Chweyah, dated 08/11/2017, indicated that the claimant presented for a follow-up visit after his discharge from the hospital on 08/08/2017. He was admitted on 08/04/2017 due to normocytic anemia, pain in both knees, starvation ketoacidosis, hypertension, gout with tophus, and duodenitis. The esophagogastroduodenoscopy revealed erythematous duodenopathy, erythematous mucosa in the antrum, and small hiatal hernia. He had a colonoscopy which revealed internal hemorrhoids. Objective findings showed blood pressure of 112/86 with a pulse of 105. He was diagnosed with quadriceps weakness, pain in both knees, normocytic anemia, type 2 diabetes mellitus, hypertension, stable chronic kidney disease stage III, and bilateral impacted cerumen. It was noted that he can return to work on 08/16/2017 with limitations of not standing for more than 10 minutes at a time for 1
“The colon cancer vs. Crohn’s disease debate is generating a lot of interest in the medical community. Every year in the U.S., approximately 57,000 people die from colorectal cancer and 147,000 new cases are diagnosed”states Dr. Victor Marchione. Crohn's disease is a new disease that was introduced into today's society in 2015. 1.4 million Americans have Crohn’s disease or ulcerative colitis. Of those, about 700,000 have Crohn’s has been diagnosed in the years between 1992 and 2004 just from a doctor's visit. People have came up with different ways that we can help and prevent the disease such as Surgery, Conferences and “ KEY TO PROCESS “.
Thus allowing me to form a differential diagnosis and rule out certain causes, such as; constipation, and indigestion. Subsequently, the physical examination enabled me to confirm a diagnosis of acute abdomen. As the patient was not experiencing any worrying (red flag) symptoms associated with abdominal emergencies, such as; appendicitis or pancreatitis. However, I did forget certain aspects of the physical examination and had to be prompted by the MO. Although with more practice such incidence would be reduced.
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During the small bowel series, the radiologist was not able to determine the exact area of obstruction. The study was terminated after two hours and the patient was returned to her room. Following the small bowel series, the patient complained of abdominal pain and cramping. The patient’s tube was leaking bowel from the side of the tube and onto her abdomen. It was also noted that her parenteral nutrition was not adequate (LWR radiology, 2015).
Dr. Imran Haque is a medical doctor in Asheboro who specializes in internal medicine. With over 19 years’ experience in the medical field, Dr. Imran Haque has made a positive contribution to the residents of Asheboro, Ramseur, and the surrounding areas and is highly respected. He graduated from the University of North Carolina. Dr. Haque acquired his training from the University of Virginia Internal Medicine Roanoke-Salem Program and is currently licensed to practice medicine in North Carolina. He also took part in the maintenance of Certification Program for Internal Medicine among other programs that are medicine related. Dr. Imran Haque is affiliated with several hospitals in Asheboro including Randolph Hospital, Southeastern Regional Medical